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TREATISE 



ON THE 



n 

DISEASES OF THE EAR, 



INCLUDING THE 



ANATOMY OF THE ORGAN, 




ANTON VON TROLTSCH, M. D., 

PROFESSOR IN THE UNIVERSITY OF WURZBURG, BAVARIA. 



TRANSLATED AND EDITED 



BY 



D. B. St. JOHN ROOSA, M. A., M. D., 

CLINICAL PROFESSOR OF THE DISEASES OF THE EYE AND EAR IN THE UNIVERSITY 
OF NEW YORK, SURGEON TO THE BROOKLYN EYE AND EAR HOS- 
PITAL, FORMERLY SURGEON TO THE NEW YORK 
EYE AND EAR INFIRMARY, ETC. 



Secoito American, from t|je fourti) German Suction. 



( 



WILLIAM WOOD & CO. 

NEW YORK. 

1869. 



-&V\$4r£ 







Entered, according to Act of Congress, in the year 1869, by 

D. B. St. JOHN ROOSA, 

In the clerk's office of ^the district court of the United States for the southern district of 

New York. 



THIS TRANSLATION 



Iftespntfttllg Beirtcateir 

TO 

ALFRED C. POST, M. D., 

PROFESSOR OF SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK, CONSULTING 
SURGEON TO THE NEW YORK AND ST. LUKE'S HOSPITALS, 



WHO, BESIDES HIS USEFUL LABORS IN THE FIELD OF GENERAL MEDICINE, HAS 

ACCOMPLISHED MUCH FOR AURAL SURGERY, AND TO WHOSE 

QUALITIES AS A TEACHER, SURGEON, AND A MAN, 

THIS GRATEFUL TESTIMONY IS BORNE 

BY HIS 

OBLIGED FRIEND AND FORMER 

PUPIL. 



TRANSLATOR'S PREFACE. 



This work has been out of print for some time, 
but circumstances beyond the control of the editor, 
have prevented the earlier publication of the present 
edition. 

Although this volume is nominally a revised edi- 
tion of the former one, it is in fact a new work. 
It is translated from the fourth German edition, to 
which the author has made large additions. The 
original has also been greatly improved by a tho- 
rough revision, and in many parts it has been entirely 
rewritten. 

The editor has also added numerous illustrative 
cases, both from his own practice and that of others. 
Many new engravings, and a copious index, have 
been added. In some rare instances, where the 
experience of the editor has led him to form dif- 
ferent opinions from those entertained by the author, 
he has not failed — with modesty it is hoped — to 
express them. 



vi translator's preface. 

The additions made by the editor will be found 
enclosed in parentheses, and further indicated by the 
initials, St. J. R. It will be observed that these 
additions and changes by the author and editor have 
doubled the number of pages in the volume. 

The science of Otology is fast taking its place in 
the van of the great movement in the ranks of 
Medicine. Diseases of the Ear are now receiving 
that attention which humanity has vainly demanded 
of our profession for centuries. Congratulating his 
readers upon this new epoch in medical science, the 
editor hopes that this translation of the work of one 
of the leaders in this onward movement, may be 
found to be an acceptable text-book for those who 
wish to study the diseases of the organ of hearing, 
and that it may receive the same hearty reception 
that was given its immediate predecessor. 

The editor has been assisted in the preparation of 

the translation of the lectures on the anatomy of the 

ear, by his friends Dr. Rider, of Rochester, N. Y., 

and Dr. Kipp, of Newark, N. J. He desires also 

to present his acknowledgments to Dr. Beard, of 

this city, for valuable assistance in the preparation of 

the work for the press. 

151 Lexington Avenue, New York, 
December, 1868. 



AUTHOR'S PREFACE 

TO THE FIRST EDITION 



I scarcely need to apologize to my professional 
brethren for the attempt here made to present a 
text-book which should embrace the whole field of 
aural medicine and surgery, and be chiefly founded 
upon my own observations and investigations. If I 
require any justification for this endeavor, it may be 
found in the dissevered position which Otology still 
holds, both in science and practice, as well as in the 
rarity of strictly scientific and independent labors in 
this field. 

I chose the form of academical lectures, as the 
one in which my thoughts should be expressed, be- 
cause it seemed to me that a certain brevity of ex- 
pression, as well as a reiteration of firmly established 
truths, rather than a full consideration of subjects 
still under discussion, and consequently unsettled, 
would increase the value of a work intended for the 
practitioner. 



Vlll AUTHOR S PREFACE. 

By thus doing, I have been enabled to cut short all 
historical considerations, and critical estimations of 
what has been accomplished, much more than would 
have been allowable in another kind of a text-book. 
I believe my readers will thank me for the latter, 
especially. 

All detailed anatomical descriptions are also omit- 
ted. They may be found in my work on the 
anatomy of the Ear 1 (Wiirzburg, i860), to which I 
beg leave to refer my readers in all anatomical ques- 
tions. I have been at times obliged to repeat myself, 
lest there should be a want of clearness in some of 
the statements. I also hope that no one will deem 
it any objection to my work, that I have freely, and 
even literally, in some places, incorporated in this 
work the results of my previous investigations on 
some subjects, for instance, on the examination and 
diseases of the external ear, catheterization, and per- 
foration of the mastoid process. 

One of our most intellectual thinkers, the aestheti- 
cal Fischer, has said, that the road to knowledge 
must always be traveled with resignation, and that 
this resignation comprises two things — patience with 
slow progress in a strictly methodical manner, and an 
intentional renunciation of the whole of truth. It is 
only by being contented with thoroughly working 
up and investigating individual points in the peri- 
phery, that we at last succeed in getting a better 

1 This work is incorporated in this edition. 



author's preface. ix 

view of the center, and finally, in our advance, we 
may penetrate it from several points. 

The profound wisdom of this declaration, is per- 
haps nowhere more plainly shown than in investiga- 
tions in the province of natural science. In such 
investigations a true enthusiasm for the subject will 
much more frequently express itself in those pains- 
taking and plodding labors, peculiar to the Germanic 
race above all others, than in any free flights of fancy 
which would fill up deficiencies in knowledge, or 
combine facts together in such a way as to give a 
satisfactory and pleasing retrospect of what has been 
achieved. 

If such a patient and slow, strictly methodical 
labor, proceeding under constant self-criticism from 
the periphery towards the center, is anywhere 
demanded, it is in the science of Otology, for the 
building up of which, fit material is yet to be pro- 
cured, and solid foundations are still to be laid. 

Here, each new, well chiselled, solid stone is of 
great and enduring worth, for, from these is to be 
obtained an increasingly stable foundation for a struc- 
ture which shall gradually grow inhabitable. 

It is certainly easier and quicker to rear a wooden 
edifice, which with gorgeous adorning may dazzle 
the eye, and whose color and ornaments may for a 
time beguile the ignorant into the belief that it is of 
stone, but time always exercises a just criticism, and 



x author's preface. 

ere long such a worthless structure will be exposed 
to every gaze, in its real hollowness, while it falls 
emptily to pieces. 

If I have anywhere formed wrong conceptions of 
facts, or explained them incorrectly, I shall be thank- 
ful for the proper information, and will gladly avail 
myself of any better knowledge. 

I hope I may succeed in winning additional co- 
laborers in the field of Aural Surgery, since it is an 
equally grateful field, both in a practical and scien- 
tific point of view. I trust, also, that I have con- 
tributed towards obtaining for this specialty the 
esteem which is its due. 

Wurzburg, May, 1862. 



CONTENTS. 



LECTURE I. 

INT RTO D U C T I N . 

The great importance of diseases of the ear, as affecting the indi- 
vidual, his position in life, longevity and intellectual development ; 
their very great frequency j the scientific position of aural medi- 
cine and surgery, _______ i 

LECTURE II. 

ANATOMY OF THE EXTERNAL EAR. 

I. Auricle and External Auditory Canal. 
Physiological and anatomical division of the auditory apparatus ; the 
auricle (its physiognomic significance); the structure of the ex- 
ternal auditory canal in the child and in the adult ; development 
of the osseous meatus, and the deficiency of ossification in the 
anterior wall ; structure and attachment of the cartilaginous 

meatus ; direction and course, size and form of the meatus ; its 
* 

integumentary lining ; relation of its walls to the parotid gland, 
the maxillary articulation, and the dura mater ; vessels and 
nerves, - - - - - - - - -n 

LECTURE III. 

ANATOMY OF THE EXTERNAL EAR. 

II. Membrana Tympani. 
mportance of a thorough knowledge of the membrana tympani ; 
it must be studied on the living subject rather than on the cadaver ; 
Rivini's foramen ; arrest of development ; attachment (sulcus and 



Xll CONTENTS. 

annulus tympanicus) ; size in the adult and in the foetus ; the han- 
dle of the malleus ; umbo ; posterior and anterior pouch ; curva- 
ture and inclination of the membrana tympani ; its color ; luster ; 
triangular spot of light; its anatomical structure; its outer and 
inner covering, and fibrous layer ; vessels and nerves, - 25 

LECTURE IV. 

DISEASES OF THE AURICLE. 

Contusions ; othatomata ; incised and other wounds ; tumors ; acute 
and chronic eczema ; the auricle in the gouty diathesis ; mal- 
formations, - - - -- ---49 

LECTURE V. 

THE EXAMINATION OF THE EXTERNAL AUDITORY CANAL AND MEM- 
BRANA TYMPANI. 

Importance of the examination of the external ear in the diagnosis 
of aural disease, and for science in general ; the aural speculum ; 
the illumination with the concave mirror, as compared with the 
methods formerly employed ; historical ; the angular forceps, 58 

LECTURE VI. 

THE SECRETIONS OF THE AUDITORY CANAL, AND THEIR ANOMALIES. 

Diminished secretion of cerumen ; the importance traditionally as- 
cribed to it ; plugs of cerumen ; their gradual accumulation and 
sudden manifestation ; their structure and causes ; vertigo and 
other symptoms ; prognosis and treatment, 75 

LECTURE VII. 

SYRINGING THE EAR ; FURUNCLES IN THE AUDITORY CANAL, 91 

LECTURE VIII. 

DIFFUSE INFLAMMATION OF THE AUDITORY CANAL, OR OTITIS 

EXTERNA. 

Periostitis of the auditory canal, as a rule, not an independent pro- 
cess ; different causes for otitis externa ; acute form, with its sub- 
jective and objective symptoms ; differential diagnosis ; the chronic 
form, .--_-____ I0 3 



CONTENTS. Xlll 

LECTURE IX. 

otitis externa (continued). 
Consequences ; prognosis ; treatment ; vesicants, cataplasms, and 

instillations of various oils. 

Abstraction of Blood in Aural Disease. 
Choice of point of application of leeches ; precautions in their use. 

Narrowing of the Auditory Canal. 
Exostoses and hyperostoses, - - - - - 116 

LECTURE X. 

INFLAMMATION AND INJURIES OF THE MEMBRANA TYMPANI. 

Affections of the membrana tympani very common, but seldom 
occurring alone and uncomplicated ; acute and chronic myringitis j 
bad effect of cold upon the ear ; lacerations and perforations of 
the membrana tympani ; several cases of fracture of the handle of 
the malleus, -----___ jo$ 

LECTURE XI. 

ANATOMY OF THE MIDDLE EAR. 

The cavity of the tympanum ; general view ; outer wall, or mem- 
brana tympani ; floor, or wall of the jugular fossa ; roof, or wall 
of the membranes of the brain ; (fissura petro-squamosa j ) inner 
wall, or wall of the labyrinth ; (fenestrae ovalis and rotunda ; pro- 
montory ; carotid artery and venous sinus ; the relations of the 
facial nerve to the cavity of the tympanum ; muscles of the cav- 
ity ; projection inward of one of the semi-circular canals ;) poste- 
rior wall, or wall of the mastoid process ; opening of the Eus- 
tachian tube into the cavity of the tympanum ; topographical 
view ; the different diameters of the cavity of the tympanum ; its 
mucous membrane in the adult and the foetus, - - 154 

1 

LECTURE XII. 

ii. anatomy of the middle ear. 

The Mastoid Process. 

The horizontal and the vertical portion. 

The Eustachian Tube. 
formation and length j isthmus of the tube ; tympanic orifice ; 



XIV CONTENTS. 

pharyngeal orifice ; construction of the cartilaginous portion ; mu- 
cous membrane ; caliber ; the muscles of the tube and their func- 
tion. 
Vessels and Nerves of Middle Ear, - - - 177 

LECTURE XIII. 

CATHETERIZATION OF THE EUSTACHIAN TUBE. 

The history of the subject ; common errors in the use of the cathe- 
ter ; method of introduction ; accidents which may occur ; spasm 
of the aesophagus ; emphysema ; hemorrhage ; description of the 
catheter, - - - - - - -- 199 

LECTURE XIV. 

THE PRACTICAL VALUE OF CATHETERIZATION OF THE EAR. 

Diagnostic value ; auscultation of the ear ; the otoscope and air bath ; 
manifold use of the catheter in the treatment of diseases of the 
ear; effect of the air bath; the catheter as a vehicle for intro- 
ducing gaseous and solid substances into the middle ear ; rubber 
air bag ; compression pump ; instrument for holding the catheter 
in position, -_-_-_-_ 213 

LECTURE XV. 

Valsalva's and Politzer's method of inflating the middle ear; other 
inferior methods, - - - - - - - 231 

LECTURE XVI. 

METHOD OF EXAMINING THE ACUTENESS OF HEARING. 

The power of hearing the tick of a watch and understanding con- 
versation, as compared with each other ; watching the mouth of 
the speaker, by a person with impaired hearing ; how a measurer 
of the degree of acuteness of hearing should be constructed ; bet- 
ter hearing in the midst of sounds; excessive acuteness of hear- 
ing ; conduction of sounds through the bones of the head ; testing 
ing the reflection of sounds, - 249 

LECTURE XVII. 

SIMPLE ACUTE AURAL CATARRH. 

Different forms of catarrh of the middle ear ; acute catarrh, its 
symptoms and consequences ; treatment, - 264 



CONTENTS. XV 

LECTURE XVIII. 

SIMPLE CHRONIC AURAL CATARRH. 

Its varieties ; sclerosis ; catarrh of the tube, and true catarrh of the 
middle ear ; pathological anatomy ; course and subjective symp- 
toms ; some peculiar " nervous " symptoms ; an attempt to ex- 
plain them, ________ 280 

LECTURE XIX. 

CHRONIC NASO-PHARYNGEAL CATARRH AS ONE OF THE SYMPTOMS 
OF CHRONIC AURAL CATARRH. 

The anatomical and physiological connection between the ear and 
pharynx ; relations of the muscles of mastication to the ear ; rhi- 
noscopy and the pathological appearances in the naso-pharyngeal 
space ; a case of formidable rusty-colored expectoration from the 
pharynx ; symptoms of chronic pharyngeal catarrh ; nerve supply 
of the pharynx, _______ 296 

LECTURE XX. 

simple chronic catarrh (continued). 
Comparative frequency ; hereditary predisposition ; appearance of the 
membrana tympani ; auscultation of the ear ; kind and degree of 
the impairment of hearing ; participation of the mastoid process ; 
prognosis in accordance with the different varieties of chronic 
catarrh, - - - - - - - - - 318 

LECTURE XXI. 

TREATMENT of chronic catarrh of the ear. 

Local treatment of the ear ; air bath or douche ; vapors and gases ; 
mechanical methods if dilatation ; agents acting upon the outer 
surface of the membrana tympani ; carbonic acid, compressed air, 
etc. ; treatment of the mucous membrane of the pharynx ; cauter- 
ization -, gargling, and its mechanical importance ; pharyngeal and 
nasal douche ; posterior nares syringe ; excision of the tonsils and 
uvula ; consideration of the patient's general condition, - 346 

LECTURE XXII. 

ACUTE OTITIS MEDIA, OR ACUTE PURULENT CATARRH. 

Different forms of aural catarrh j symptoms, prognosis and treatment 
B 



XVI CONTENTS. 

of acute otitis media ; it is often overlooked, or not properly re- 
garded ; the different forms of deafness in typhus and typhoid 
fever ; manner in which perforation of the membrana tympani 
occurs. 

PARACENTESIS OF THE MEMBRANA TYMPANI. 

Historical ; method of performance ; its employment for the evacu- 
tion of pus, mucus and blood from the cavity of the tympanum, 
in acute myringitis and adhesion of the Eustachian tube; its 
value as a method of diminishing deafness and noise in the ears ; 
difficulty in maintaining the opening, - - - 375 



LECTURE XXIII. 

PURULENT AURAL CATARRH IN CHILDREN. 

Up to this time chiefly known through pathological study ; an 
attempt at an explanation, and its practical value ; Dr. Wreden's 
cases, - - - - - - - - - 391 

LECTURE XXIV. 

CHRONIC PURULENT AURAL CATARRH, OR CHRONIC OTITIS MEDIA. 

Objective and subjective symptoms ; treatment ; perforation of the 
membrana tympani ; its importance, and the frequency with which 
it heals. 

THE ARTIFICIAL MEMBRANA TYMPANI. 

Historical; the various kinds ; principle on which it acts, - 411 

LECTURE XXV. 

THE RELATIONS OF SUPPURATION IN THE EAR TO THE GENERAL 

SYSTEM. 

Caries of the petrous portion of the temporal bone and its conse- 
quences — cerebral abscess, purulent meningitis, paralysis of the 
facial nerve, destruction of the walls of the vessels; the influence 
of suppurative inflammations of the ear upon the vascular sys- 
tem — embolia, septic infection, metastases; tuberculosis and 
cholesteatoma of the petrous portion of the temporal bone, 433 



CONTENTS. XV11 

LECTURE XXVI. 

PROGNOSIS AND TREATMENT OF SUPPURATION IN THE EAR. 

Difficulty of the diagnosis, " caries of the petrous portion of the 
temporal bone ; " the relations of patients with otorrhoea to mili- 
tary service and life insurance companies ; thorough cleansing of 
the ear; manner of using astringents, and their selection; consi- 
deration of the general condition ; local blood letting ; incision 
behind the ear and in the auditory canal ; secondary affections of 
the auditory canal ; trephining the mastoid process ; its indications 
and history ; removal of sequestra, - - - - 452 



LECTURE XXVII. 

AURAL POLYPI. 

Their origin and structure ; treatment. 

FOREIGN BODIES IN THE EAR. 

Most of the methods of extraction more dangerous than the foreign 
bodies ; an operation proposed for doubtful cases ; foreign bodies 
in the ear often the cause of peculiar reflex symptoms ; several 
cases, _--__-.___ 475 



LECTURE XXVIII. 

nervous deafness. 
Anatomy of the Internal Ear. 

Nervous deafness ; want of exact anatomical and clinical proofs of 
its existence ; a case of sudden deafness occurring in an artillerist ; 
disease of the semi-circular canals, with cerebral symptoms 
(Meniere) ; secondary affections of the labyrinth very common ; 
Helmholtz's theory, and partial paralysis of the organs of Corti ; 
deafness in intra-cranial disease ; (aneurism of the casilar artery, 
epidemic cerebro-spinal meningitis ; diagnosis ; general remarks on 
the relative infrequency of primary affections of the labyrinth, 493 

LECTTRE XXIX. 

NOISES IN THE EAR, OR TINNITUS AURIUM. OTALGIA, - 518 



XV111 CONTENTS. 

LECTURE XXX. 

DEAF-MUTEISM. 

Its nature, and the causes of its origin ; medical and educational 

treatment. 

THE APPLICATION OF ELECTRICITY IN DISEASES OF THE EAR. 

Faradization of the ear ; the constant current. 
Ear Trumpets, _______ $^3 

LECTURE XXXI. 

the examination of patients. 

Post mortem Examination of the Ear, _ _ _ 549 
Index, _________ 561 

Errata, -_----___ 566 



ILLUSTRATIONS. 



Fig. Page. 

i. Topographical view of the entire auditory apparatus, - 12 

2. Vertical section of the osseous meatus, right side, close to 

the membrana tympani, - 22 

3. Membrana tympani, as seen from auditory canal (Gruber), 28 

4. Membrana tympani seen from the cavity of the tym- 

panum (Gruber\ ------- 30 

5. Ear specula (exact size), ------ 63 

6. Author's concave mirror (actual size), - - - . - 67 

7. Translator's forehead band, ----- 68 

8. Method of examining the ear, - r - - - 70 

9. Angular forceps, ------- 74 

10. Metal ear syringe, - - - - - - -92 

1 1 . India-rubber ear syringe, - • - - - - - 94 

12. Clarke's ear douche, -------95 

13. Scalpel, and Daviel's spoon, - - - - - 101 

14. Superficial view of the labyrinth wall of the cavity of the 

tympanum, -------- 163 

15. Vertical section of the cavity of the tympanum, continued 

though the membrana tympani and auditory canal, - 171 

16. Transverse section of cartilaginous portion of Eustachian 

tube at about the middle of its course (magnified five 
diameters), - - - - - - - -182 

17. Eustachian catheter, - - - - - - 201 

18. Gutta percha air bag, ------- 208 

19. Otoscope or diagnostic tube, - - - - - 215 

20. Air receiver and pump, - - - - - -226 



XX ILLUSTRATIONS. 

Fig. Page. 

21. Glass flask for generating vapor, - 227 

22. Apparatus for generating muriate of ammonia, - - 228 

23. Spectacle forceps, ------- 229 

24. Nose forceps, - -,- - - - - - 230 

25. Politzer's method of inflating the cavity of the tympanum, 235 

26. Politzer's manometer, ------ 244 

27. Politzer's air bag with inhaler attachment, - 247 

28. Siegle's aural speculum, - - - - - 286 

29. Tobold's illuminating apparatus, ----- 306 

30. The posterior nares as seen in rhinoscopy (Mackenzie), 311 

31. Tube for injecting the nostrils, - - - - 367 

32. Posterior nares syringe, ------ 369 

33. Bishop's nebulizer for Eustachian tube, - 370 

34. Artificial membrana tympani, ----- 422 

35. Method of applying artificial drum ( Toynbee\ - - 423 

4 " > Sequestra removed from internal ear (Agnew\ - - 472 

38. Wilde's polypus snare, ------ 480 

39. Caustic-holder, - - - 482 

40. Elastic hearing tube, ------ 546 



BtoasFS mi Snaking of I|f Cfflr. 



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LECTURE I. 

INTRODUCTION. 

The great importance of diseases of the ear, as affecting the 
individual, his position in life, longevity and intellectual 
development; their very great frequency ; the scientific posi- 
tion of aural medicine and surgery. 

Gentlemen : There is scarcely any department of the 
science of medicine in which there is, even at this day, so 
much ignorance of facts, and such a want of positiveness 
of opinion, as in aural medicine and surgery. I therefore 
consider it to be my duty, before we begin any closer con- 
sideration of the subject of these lectures, to make a few 
remarks on the importance of aural diseases in general, as 
well as, upon the scientific position of aural medicine and 
surgery. 

Diseases of the ear are among the most serious and fre- 
quent affections to which the human system is exposed. 
This statement is quite the contrary to what is generally 
heard and read on this subject, and it is probably quite the 
contrary of what you have heard and thought on the same 
subject. But in spite of this, my statement is the correct 
one, as I hope in a short time to be able to demonstrate 
to you. Let us, however, enter at once upon our theme. 

In the first place let us speak of deafness. This is by 
far the most frequent of the consequences of aural affections. 
No one certainly will deny that every high degree of im- 
i 



IMPORTANCE OF HEARING. 





pairment of hearing, is a very serious affection to the person 
concerned, in all his relations ; because it limits very much 
his intercourse with others, and when it increases to a 
great extent it may entirely destroy his capability for 
business and social intercourse. Deafness also impairs the 
noblest of our functions, our capability for life among 
others. But it is not only the unrestricted enjoyment of 
life, which is thus greatly impaired by deafness, but many 
persons are affected in their vocation, in the exercise of their 
calling, and in their capability of securing a livelihood, 
by a loss of their hearing. Imagine for a moment that 
one of you becomes deaf; in what a position you are 
placed, as soon as you are obliged to confess that you are 
no longer capable of answering the requirements which your 
every day practice makes of the acuteness of your senses. 
Teachers, military officers and public officials are also, not 
unfrequently compelled to give up their position on account 
of impairment of hearing. 

Not less important is the influence which impairment 
of hearing exerts upon the intellectual development of a 
child. If man be a creature of circumstances, the reciprocal 
relation should be considered, which exists between the 
acuteness of the senses, and clearness of thought. Nil in 
intellects, quod non prius fuerit in sensu, says Aristotle. The 
beginning and basis of all knowledge is the sense of expe- 
rience. The impression of external objects, as they are 
carried bv the senses to the brain, furnishes to the intellect 
the materials for the formation of ideas. In proportion 
as the impressions which the outer world makes upon the 
sensorium are sharp and clear, that is, the more acute our 
senses are, so much the more plainly and certainly will our 
views and ideas express themselves. If, on the contrary, 
the sensitive perceptions of a person are not clear, if they 
are partial and undecided, his whole nature and character 
will bear the same stamp of incompleteness and uncertainty. 



IMPORTANCE OF HEARING. 3 

By what way, we may ask, is the material for the intel- 
lectual development of the child conveyed to him ? Un- 
doubtedly through the ear. On this account, impairment 
of hearing occurring in early life, acquires a more or less 
permanent influence upon the formation and development 
of the intellectual nature, according as education and care 
resist these evil influences. Such children are not only 
unable, except with great difficulty, to concentrate their 
attention, but they are apt to remain inattentive and fickle, 
while the want of an acute perception, which is chiefly 
attained through the ear, renders a closely connected train 
of thought and a comprehensive grasping of intellectual 
and sensuous perceptions very difficult. People who from 
early life have been somewhat hard of hearing, have gene- 
rally something in their nature a little foggy, are uncertain 
and weak in business, illogical and superfluous in thought 
and speech, abrupt and out of character in their answers. 
Hence, an experienced and attentive physician is not un- 
frequently able to decide, from the speech and bearing of 
a patient, after a short conversation, that he has probably 
not heard well since early childhood. 

All this is true of a moderate amount of impairment of 
hearing. If it be of high degree, the child who does not 
hear speech does not learn to speak at all, or, if older, he 
forgets the sound of the words, and in either case becomes 
completely dumb as well as deaf. I do not need to tell 
you that a deaf and dumb person, even under the best 
method of instruction, can never be made an equal, useful 
member of society. 

But in another respect affections of the ear are among 
those which make themselves felt in an extremely unplea- 
sant manner. I have only to remind you of the subjective 
sounds in the ear, tinnitus aurium, in its various forms, 
which to many patients is much more troublesome than the 
impairment of hearing. This makes such an impres- 



4 TINNITUS AURIUM. 

sion upon some patients, it is so confusing and disturbing 
to the senses, that its subjects are brought to a condition 
bordering on insanity. 

I may also remind you of the fearful pain connected 
with many inflammations of the ear, and which often cause 
the most stolid and enduring men to shriek with agony. 
Added to all this, affections of the ear, especially those 
attended by suppuration, not unfrequently end in death. 
From neglected and long existing affections of the ear, 
cerebral abscesses, purulent meingitis, or pyaemia, are quite 
often developed, as each one of you has had occasion to 
see in the medical clinic. 

Thus we see that diseases of the ear arrange themselves 
among those classes of affections which exert the deepest 
and most destructive influence ; and that this influence 
extends even to the intellectual development, and upon 
the duration of life of the individual. Certainly they 
have a greater influence in these respects than diseases of 
the eye. It cannot be their harmlessness, then, which 
causes physicians to neglect them. 

Diseases of the ear are besides very common. Most 
physicians believe that it is hardly worth the trouble to 
interest themselves in them because they are so rarely 
called upon for their treatment. But this is a very great 
error. There is an astonishingly large number of ear 
patients ; and when we examine the matter a little more 
exactly, perhaps there are more ear than eye patients. I 
only need to remind you how frequently the ear is affected 
in a certain class of constitutional affections. This is 
almost regularly the case in measles, scarlet fever and small 
pox ; and it is very frequently affected in typhus fever, 
in tuberculosis, and whooping cough, whilst some very 
common and every day diseases, such as nasal and pha- 
ryngeal catarrh, almost always affect the ear. Remember, 
moreover, that nearly all who have passed the age of fifty 



FREQUENCY OF DISEASES OF THE EAR. 5 

or sixty years no longer hear well ; a fact to which we 
are so accustomed that we are inclined to consider it 
as a physiological condition. Consider further that in 
childhood purulent discharges from the ear are not uncom- 
mon, whilst earache is so frequent that nearly all children 
suffer more or less from it. In middle age, also, diseases 
of the ear are still frequent ; and a great proportion of 
individuals at this age will show, by accurate examination, a 
diminution in the acuteness of hearing, either on both sides 
or one side only. Many of your acquaintances can aus- 
cultate with the one ear only — " from habit," they per- 
haps believe, but in truth because the hearing in the 
other ear has become impaired, although they may not be 
conscious of the fact. The ordinary duties of life not 
requiring perfectly acute hearing, it must become con- 
siderably impaired in order to interfere with our social 
intercourse. Deafness on one side only, is especially apt 
to escape the notice not only of others, but also of the 
patient himself. 

Although it is difficult to make a definite estimate of 
the proportion of individuals whose hearing is more or 
less impaired, still I believe I shall make too small rather 
than too large an estimate, when I assert that not more 
than one out of three persons of from twenty to forty 
years of age still possesses good and normal hearing. You 
will notice this fact in your practice. At first you will hear 
but little of ear diseases, until, by some fortunate accident, 
the people learn that an aurist lives among them. Then 
suddenly a great number of patients will appear, and many 
of them will be of your acquaintances, and persons whom 
you had not suspected as suffering from diseases of the 
ear. 

Diseases of the eye are not easily concealed, whilst dis- 
eases of the ear very frequently escape our notice, either 
with or without the connivance of the patient. Believe 



6 FREQUENCY OF DISEASES OF THE EAR. 

me, the number of ear patients is enormously great, and 
this number will apparently still further increase when there 
are more surgeons to recognize and treat them ; for hitherto 
these diseases have been either unnoticed at their begin- 
ning, or intentionally concealed. The fact that physicians 
have so far troubled themselves so little about ear diseases 
cannot therefore depend upon a want of material. 

Since, therefore, the diseases of the ear are so frequent 
and their results so important, influencing, as they do, the 
happiness of the individual, his social position, his mental 
development, and even endangering his life, what would be 
more reasonable than to suppose that the attention of 
physicians would have been directed in a corresponding 
manner to their treatment ? You know, however, very 
well, that, this department of medicine has been neglected, 
and that the development of aural surgery has not kept pace 
with the other departments of medical science. Whilst 
other parts of medicine were emerging from the mists of 
philosophical speculation into the domain of sober facts, 
derived from observations upon the living subject and 
the cadaver, which alone can form a safe foundation 
for therapeutics, a considerable time elapsed before aural 
surgery chose this safe and certain stand-point. In Ger- 
many, especially — and this we confess to our shame — 
there ruled an obstinate, intolerant dogmatism, which com- 
pletely neglected investigations on the cadaver, and made 
observations on the living subject in a very superficial 
and careless manner only. The physicians who busied 
themselves with this branch of medicine were very few, 
and the universities quite ignored it. Hence even accom- 
plished physicians knew but little about ear diseases ; and 
it was but natural that aural surgery should remain far 
behind the other departments of medicine, which had able 
representatives in the universities, and abundant develop- 
ment among the profession in general. 



NEGLECT OF STUDY OF DISEASES OF THE EAR. J 

It gradually became the custom, however, to ascribe the 
want of practical results and scientific progress to the nature 
of the subject itself, and to deny that there was any capa- 
bility of development and accomplishment in the study 
of diseases of the ear. The cases of aural disease were 
dismissed with the assertion, that there was nothing to 
be done for the'm. Now add to all this, the fact, that 
among those who especially cultivated this field of science, 
incessant literary contention occurred. One of these dispu- 
tants was noted for his arrogance, another for his sordid 
manner of treating the whole subject, while a third pub- 
lished the most frivolous hypotheses. You will easily 
understand how physicians placed little confidence in 
researches and labors, exhibiting so little that was really 
valuable and so much that was disagreeable. At last, 
everything that merely reminded the profession of aural 
I disease was received with antagonism, or jeering mirth. 
! So that so late as 1856, it was openly declared to your 
\ lecturer, that one who became an aural surgeon, would put 
his good name in jeopardy. 

In order that diseases of the ear may receive the atten- 
tion that their importance demands, aural medicine and 
surgery must endeavor to elevate itself, in a scientific and 
ethical point of view. A very great influence for the 
scientific reformation of this department proceeded from 
•Great Britain. 

Wilde of Dublin and 'Toynbee of London (the former is 
still living, the latter died in July, 1866), contributed 
most to this change ; the former by his very careful clinical 
observations of the course of the diseases of the ear, and 
of the objective appearances especially, of the membrana 
tympani ; the latter by his numerous sections of the auditory 
apparatus, as well as by various contributions to our ana- 
tomical and physiological knowledge of aural disease. 
The critical German spirit immediately recognized cer- 



8 



LABORS OF WILDE AND TOYNBEE. 



tain one sided views in the diagnosis and treatment of 
aural disease, such as are even yet prevalent in England, 
and very soon there arose among «us a zealous desire for 
a wider and independent building up of this science. From 
year to year the number of physicians increased, who took up 
the study of aural disease with interest, and who had a proper 
understanding of the subject. In one medical school after 
another teachers arose, who prepared the way for progress in 
a fundamental knowledge of this specialty. Hand in hand 
with this there was a very great increase in the force engaged 
in teaching and practising in this department — afield only 
a short time before uncultivated — and a new life was begun. 

The results of former observation were reexamined in 
the light of new anatomical and physiological ideas, fur- 
nished by modern methods of examination and treatment ; 
and thus, a large and varied experience was acquired which 
furnished the unprejudiced observer with a great number 
of new points of observation and altered views. 

Corresponding to this undeniably great scientific pro- 
gress in all directions, which to a great extent was made 
practically available, the interest of the profession at large 
in the affections of the organ of hearing also increased. 
Where there was formerly slight estimation and derision, 
we now find a ready recognition of what has been accom- 
plished, a proper estimation of the subject, and abundant 
belief in the future. In the same way, the laity not less 
than the profession, gradually begin to give to diseases of 
the ear the consideration that their serious character de- 
mands. It is only a dull or short sighted observer that 
will now deny that this whole matter has very recently 
changed its position in all respects. 

It is true, however, that very much remains yet to be 
done and to be desired. We as yet have seen only the 
proper beginning. It must be considered a very con- 
siderable progress that the gaps and deficiencies in our 



NEEDS OF AURAL SURGERY. 9 

knowledge are now more clearly and distinctly seen ; that 
the ends to be yet attained are more decided, and the way 
for future progress is opened up in many directions. 

We now require more precision in the diagnosis and 
treatment of morbid conditions of the outer and middle 
ear, and our ideas as to independent and secondary pro- 
cesses in the nervous part of the ear, must have a firmer 
footing. It will be one of the most important tasks of 
the coming time to furnish diagnostic appliances, that shall 
enable us in all cases to furnish conclusions as to the 
condition of the nervous apparatus of the organ of hearing. 
Here, also, where science did not formerly seem to have 
even a foothold, we have very lately gained a place for 
genuine observation. 

We must, also, endeavor to bring diseases of the ear 
and their treatment beyond the narrow boundaries of an 
exclusive specialism. In consequence of the great variety 
of the symptoms proceeding from the ear, and the serious- 
ness of many of its affections, great errors in diagnosis, 
and many neglects and omissions in treatment can only 
be avoided, when a certain amount of the knowledge in 
this department has become the common property of all 
physicians, and when such a knowledge is indispensably 
required of every clinical teacher, as a prerequisite for the 
performance of his functions. The greatest possible sim- 
plification of the details of examination and treatment, 
will do very much toward rendering aural disease a subject 
for investigation and treatment in the largest circles of the 
[profession. Modern time has also contributed very much 
toward this latter point. 

After this general exposition of the matter in hand, 
I have to-day to unfold to you, the plan that I shall 
follow in these lectures, and what you may expect from 
our meeting together. I shall bring before you the dif- 
ferent forms of diseases of the ear according to their 
i 



IO PLAN OF THE PRESENT WORK. 






anatomical classification, describe their symptoms and make 
you acquainted with their treatment. I shall give you 
demonstrations of what I have to say, in preparations and 
pathological specimens from my collection, and a brief 
consideration of the normal anatomy of the parts will 
precede the description of their diseases, which will be also 
illustrated by appropriate preparations. 

In connection with this theoretical instruction, I shall 
also assist you in the examination of the ear, with the 
otoscope or ear mirror, and catheter, in order that you may 
be able for yourselves to make a proper diagnosis as to 
the nature of the diseases of the ear, that may occur in 
your practice. It will please me very much, if I succeed 
in exciting in you a warm and permanent interest in the 
still much misunderstood, because not well known, dis- 
eases of the auditory apparatus. If this be the result of 
our meeting together, I know with certainty, that, in your 
subsequent life, you will thereby benefit your fellow beings 
and yourselves to a great extent, and thus derive great 
satisfaction from your labors. 



LECTURE II. 

ANATOMY OF THE EXTERNAL EAR. 

I. Auricle and External Auditory Canal. 

Physiological and anatomical division of the auditory apparatus ; 
the auricle (its physiognomic significance) ; the structure of 
the external auditory canal in the child and in the adult ; 
development of the osseous meatus, and the deficiency of ossi- 
fication in the anterior wall ; structure and attachment of 
the cartilaginous meatus; direction and course, size and 
form of the meatus ; its integumentary lining ; relation of 
its walls to the parotid gland, the maxillary articulation, and 
the dura mater ; vessels and nerves. 

Gentlemen : Before we begin the study of the diseases 
of the ear it will be necessary to become better acquainted 
with the organ itself, its situation and structure. On 
account of the directly practical aim of these anatomical 
observations we shall exclude everything which has for us 
no special importance. 

The physiologist divides the ear into two parts ; a 
perceptive, and a conducting apparatus. The anatomist 
gives the name of internal ear to the first part, i. e., the 
expansion of the auditory nerve in the labyrinth, together 
with the parts inclosing it, and divides the conducting 
apparatus, lying external to the former, into two parts, 
the middle and the external ear. The middle ear includes 
the cavity of the tympanum, the mastoid process with its 
cells, and the Eustachian tube with its muscles, while the 



12 



ANATOMY OF EXTERNAL EAR. 



external ear consists of the auricle, the external auditory 
meatus, and the membrana tympani. 



Fig. i. 




Topographical view of the entire auditory apparatus : left ear. H, 
hilix. Ah, anti-helix. At, anti-tragus. L, lobule. O, entrance to the 
meatus, of which the anterior wall, together with the tragus, has been 
removed. Afc, cartilaginous meatus. At the end of the latter is seen 
the outer surface of the membrana tympani, and the handle of the mal- 
leus. Ps, processus styloideus. Vj, internal jugular vein. Ci, internal 
carotid artery, both before and after its passage through the petrous bone. 
Lp, levator palati; s, petro-salpingo-staphylinus . Tp, tensor palati; 
s, spheno-salpingo-staphylinus (abductor, or dilator tuba). Between the 
two divided muscles is seen a part of the membranous portion of the car- 
tilaginous tube. Rp, recessus pharyngis or Roseumuller's fossa, between 
which and the sound introduced into the cartilaginous tube projects the 
posterior cartilaginous lip of the ostium pharyngeum tubes. Os, section 



ANATOMY OF EXTERNAL EAR. 1 3 

of the body of the sphenoid bone, Tt, musculus tensor tympani, running 
along the superior wall of the osseout tube, and projecting its tendon across 
the tympanum, C, cochlea, partially opened, with its opening into the 
vestibule. Cm, head of the malleus, behind it the body of the ambos. 
Above them the bony roof of the tympanum, covered by the dura mater. 
Op, oquamous portion of the temporal bone. Dm, dura mater. Mt, 
temporal muscle. 

External Ear. — We begin with the external ear. This 
presents, in general, the form of a funnel with its larger 

| opening directed outward, in order to receive external 
sounds. Its smaller and inner extremity is closed by the 

! membrana tympani which assists in the further propaga- 

\ tion of the sonorous waves. 

The auricle is an elastic expansion adapted to the collec- 
tion of sound, which it conducts into the external auditory 
meatus, in part by reflection, in part by participation in 
the sonorous vibration. In man its projection from the 
head is slight, and the development of its muscular appa- 
ratus is less than in most other mammalia. 

The auricle in common with the external meatus, the 
Eustachian tube and the mastoid process, is that part of the 

1 auditory apparatus which completes its growth and devel- 

i opment at the latest period, while the labyrinth hardly 

I increases in size after birth, and the cavity of the tympanum 
and membrana tympani increase but little. These parts are 
subjected to many changes after birth, their development 
at that period being still very incomplete. (Some parts* 

\ such as the aqueduct and anterior process of the malleus, 

I become even smaller after birth). 

In regard to the size of the auricle in the embryo, I have made a 
series of measurements and obtained the following results, which in 
doubtful cases may be of service in determining the age of the foetus. 
The longest or vertical diameter measures in a foetus of io-ii weeks, 
2 mm. ; of three months, 4-5 mm. ; of four months, S\~l\ mm ' > 
of five months, 8-12 mm.; of six months, 14-17 mm.; of seven 



14 THE AURICLE. 

months, 16-24 mm.; of eight months, 26 mm.; of nine months, 
26-28 mm. ; of the new born infant, 33-36 mm. It should be 
remarked that these measurements were made from preparations in 
alcohol. If made on the fresh subject, they might be somewhat 
greater. After birth the auricle increases much more in length than 
in breadth ; as do also the meatus and membrana tympani. 

The size and form of the auricle, and the angle which 
the auricle forms with the lateral wall of the skull, are 
subject to great individual variations. Many of these are 
frequently observed as family characteristics, while many 
may be considered as national and ethnological peculiarities. 
The auricle may vary in respect to its length or breadth, 
its roundness or angularity, its flatness or concavity. It 
often lies closely applied to the head in females, as a result 
of constant pressure from the covering of the head, or in 
children from long continued chafing at its angle of at- 
tachment. In advanced age the auricle becomes more 
relaxed. 

It is well known that Lavater attributed a certain physiognomic 
significance to the form of the auricle. Dr. Amedee Joux, 1 in more 
recent times, goes further, and draws most minute conclusions in 
regard to an individual's character from an examination of this organ. 
A white, pliant ear, of symmetrical and elegant form, with a faultless 
lobule, of becoming size, which is nicely attached to the head, can 
belong to no vulgar or even mediocre individual. But if the auricle 
be red and thick, if its lobule be large and injected, if its component 
parts be not in just proportion, if it stand in improper relation to the 
neighboring parts, if it have an animal or unpleasing shape, then its 
possessor has been slighted by nature ; his tendencies are ignoble and 
blameworthy. Joux further asserts that no other organ of the human 
body so uniformly descends, still retaining its peculiar features, from 
father to child ; and that this fact may frequently assist in determining 
the legitimacy of children, and the conjugal fidelity of a mother. 
" Montr e-moi ton oreille^je te dirai qui tu es y d'oit tu veins et oil tu vas." 

1 Gazette des Hopitaux, Fevr., 1854. 






< 



EXTERNAL AUDITORY CANAL. 1 5 

The external auditory canal is a tubular continuation of 
the auricle, from which it is separated by no well marked 
boundaries. Its outer extremity is open, whilst internally 
it is closed by the membrana tympani. The dog and cat 
are not only blind at birth ; but there also exists in them a 
condition of the auditory meatus analagous to that of the 
eyelids. On the twelfth or fifteenth day after birth, and the 
second or third day after the opening of the lids, the mem- 
brane which closes the meatus breaks up, still leaving 
remnants which partially close the entrance to the passage. 
It is possible that the stoppage of the auditory meatus 
with vernix caseosa and the proximity to each other of the 
walls of the meatus in the vicinity of the membrana tym- 
pani may constitute a similar condition in the new born 
of the human species. (As is well known, many birds have 
the enviable power of stopping their ears at pleasure by 
means of a kind of valve. The turkey possesses an erectile 
tissue projecting into the meatus, so that it can close the 
ear more or less perfectly when angered). The membrana 
tympani in the child lies at the outer surface of the skull, 
but in the adult at the bottom of an osseous canal, formed 
by the temporal bone. Hence, in the infant the passage 
leading to the tympanic membrane is formed only of car- 
tilage and soft tissue, of which a portion has become ossified 
in the adult. In the latter, therefore, we divide the meatus 
into a cartilaginous and an osseous portion. 

During the earlier period of its life the child possesses 
no osseous meatus. The statement, however, of many 
authors that the meatus of the child is wholly cartilaginous 
is incorrect. The outer portion of the passage is carti- 
laginous in both child and adult, while in the former the 
inner portion consists of a membranous tube, to which the 
cartilaginous portion is attached, precisely as it is afterward % 
attached to the osseous portion. In the newly born this 
inner, membranous portion constitutes about one-half 



i6 



DEVELOPMENT OF OSSEOUS MEATUS. 



of the whole canal ; but it gradually becames shorter as 
the development of bone progresses outwardly. (Since, 
however, the membrana tympani of the infant is nearly 
horizontal, and lies therefore in a plane with the superior 
wall of the meatus, we must limit the term membranous 
meatus, to the inner portion of the inferior and anterior 
walls). 

This slow development of the osseous meatus is only 
partially accomplished by the addition of a new osseous 
portion. The superior and posterior walls are formed by 
a change in the confirmation of the temporal bone, coinci- 
dent with the general growth of the skull. As the flat, 
undeveloped mastoid process of the child increases in size 
and convexity, the depression in the squamous portion of 
the temporal bone, at first quite superficial, and containing 
at its bottom the membrana tympani, increases in depth. 
On the contrary, an addition of osseous substance is made 
to the anterior and inferior segments of the annulus tym- 
panicus y the osseous ring which, in the foetus, is quite 
independent, and to which the periphery of the membrana 
tympani is attached. In this way there gradually arises 
an osseous plate, which is convex anteriorly, and attached 
posteriorly, to the mastoid process, superiorly to the squa- 
mous portion of the temporal bone. Thus the superior 
and posterior walls of the osseous meatus are formed in one 
way, while the anterior and. inferior walls are developed in 
another. 

This addition of osseous tissue does not progress out- 
wardly with regularity, but in such a manner as to leave at 
first a rounded notch, which finally becomes a nearly, 
circular foramen, filled up with connective tissue. 

The time required for the complete filling up of this 
foramen seems to vary materially in different individu- 
als. I looked in vain for it in the skull of a child 
i\ years old, and also of another 3 years old, while in 



OSSEOUS MEATUS OF CHILD. I J 

most cases its diameter is as great as that of a cherry pit. 
On the "skeleton of a child five years of age/' in the ana- 
tomical museum at this place, the foramen measures about 
3 mm. in diameter : and in some other skulls of young 
subjects which possess the osseous meatus of full length, 
foramina of various sizes are still present. In all others 
of this age the corresponding part of the meatus is so thin 
as to be quite translucent. 

Any one who is not aware of this peculiar method of 
ossification in the meatus of the child, might easily mistake 
this opening, with its thin and irregular margins, for a 
pathological condition, the result of caries, especially if 
the process of caries is going on the vicinity. This pecu- 
liarity is by no means generally understood. I assure 
you that even celebrated anatomists, when I have shown 
them normal preparations illustrating this peculiarity, 
have declared that the foramina were pathological. In 
inflammations of the meatus this foramen may be of further 
practical importance, since the membrane closing it may 
be easily broken through by the suppurative process, and 
the disease be thus propagated to the maxillary articula- 
tion or the parotid gland. 

The scanty accounts which we find in regard to this deficiency of 
ossification in the anterior wall of the osseous meatus of the child, 
show how little the attention of anatomists has been drawn to it. 
The fullest account of it is given by Huschke, in his edition of Som- 
mering's Anatomical Manual. 1 He asserts that it does not become 
perfectly filled up until the fourth year, and considers it the analogue 
of the incisures Santorini of the cartilaginous meatus. In Arnold's 
i Manual, 2 which in other respects treats exhaustively of the ear, it is but 
briefly mentioned. Henle 3, alludes to this foramen as an oft occurring 
"variety." Of the older anatomists, Cassebohm* (T'ractatus quatuor 
anat. de aure humana y Hala, 1734, />. 28), gives a very good account 

1 1844, p. 896. 2 1845, I, p. 402. 3 Manual 1855, p. 142 and 151. 

4Handbuch, § 142 et 157. 



I 8 CARTILAGINOUS MEATUS. 

of it : " Paries anterior in medio foramen habet, in infante aliquot an- 
norum magnum ; in juvine autem et adulto disparens, quia evaluit." 
In Tab. I, fig. 2, he shows, by means of a circle drawn on the petrous 
bone of an adult, the spot u ubi foramen in puero observatur." The 
above mentioned drawing is probably the first which was made of 
this foramen from nature. 

The length of the auditory canal varies considerably in 
different subjects. Its average length in the adult is about 
i inch, or more accurately, 24 mm. The cartilaginous 
meatus constitutes about one-third (8 mm.) of the whole, 
and the osseous meatus the remaining two-thirds (16 mm). 

The cartilage is not immediately attached to the bone, 
as is the cartilaginous Eustachian tube to the osseous, but 
the two sections of the meatus are joined by means of an 
interposed membranous layer, which may be regarded as a 
residuum of the inner membranous half of the meatus ; 
the cartilage even partially surrounds the outer border of 
the osseous canal. In this way a certain degree of exten- 
sibility of the meatus is effected, and its mobility further 
increased by the peculiar form of the cartilaginous meatus. 
This has not the form of a perfect cylinder, but only of a 
semi-cylinder, which is completed superiorly for a con- 
siderable portion of its extent by membrane, and which 
resembles the trachea in this respect, that the cartilage 
possesses several regular incisures, incisure Santorini, which 
are filled up by membranes. 

The external extremity of the cartilaginous meatus, on 
the contrarv, is on all sides continuous with the auricle. 
There are no well marked boundaries between the two, 
and every movement of the auricle is participated in by 
the cartilaginous meatus. 

In regard to the direction and course of the external 
auditory canal, as a whole, it is usual to describe so many 
curvatures, angles and projections, that the student becomes 
confused. A better knowledge may be obtained by a de- 



CARTILAGINOUS MEATUS. I 9 

scription which omits these* anatomical details. For this 
examination the living subject is better than the dead ; 
but if the latter is used the soft parts must be previously- 
hardened, since otherwise they are easily displaced by the 
dissection, and one would draw wrong conclusions in 
regard to their relations. 

The most essential factor in the production of the sinu- 
osity of the external auditory meatus is the rounded angle 
at the junction of the osseous and cartilaginous portions 
of the canal. The longitudinal axes of the two portions 
do not lie in the same plane, but meet at an obtuse angle, 
whose opening is directed downward and forward. This 
angle, which projects more or less into the caliber of the 
meatus, forms, to a certain extent, the ridge from which 
each division descends, the cartilaginous to the outer 
extremity of the canal, the osseous to the membrana tym- 
pani, both running downward and forward ; the inclination 
of the osseous portion, however, being always less than 
that of the cartilaginous. 

The inclination is always greatest along the inferior wall 
of the cartilaginous meatus. Hence it results that, while 
the membrana tympani and outer extremity of the meatus 
lie in the same horizontal plane, the outer opening lies 
much below the lower margin of the membrana tympani. 
The superior wall of the external auditory meatus runs 
also very nearly in a straight line, while the lower wall 
makes an obtuse angle at the point of junction of the 
osseous and cartilaginous portions. In the child, even 
after a part of the osseous meatus has appeared, the infe- 
rior wall is much straighter than in the adult. 

If we now examine the various diameters of the auditory 
canal, we are enabled to make certain more minute detailed 
observations in regard to the various curvatures, dilatations 
and contractions of this canal. 

It should be remarked in general, that both the caliber 



20 SIZE OF EXTERNAL AUDITORY CANAL. 

and form of the external auditory canal vary exceedingly 
in different individuals. Even in the same individual, the 
two sides are frequently unsymmetrical. In order to con- 
vince one's self of the great diversity of size and form, 
e. g., of the external extremity of the osseous meatus, it is 
only necessary to examine a number of macerated petrous 
bones. You will hardly find two alike in this respect. In 
some, the opening will be nearly circular, in others oval ; 
in one, the meatus will be nearer straight than in another, 
while the inclination of the axis of the meatus will vary. 
In the adult the transverse diameter of the canal is gene- 
rally greater than the vertical, and a section of the canal 
has always an oval or elliptic form. The longest diameter 
of this oval is nearly vertical at the outer extremity of the 
cartilaginous meatus ; but it soon changes from this vertical 
direction, and runs downward and backward. 

Just behind the tragus, which projects somewhat over 
the entrance to the meatus, the canal, in its antero-posterior 
diameter, is smaller than at any other point, while its ver- 
tical diameter is correspondingly great. Soon thereafter 
the vertical diameter decreases and the horizontal diameter 
increases, the canal becoming lower and broader. There 
is another contraction in the transverse diameter a short 
distance from the membrana tympani, and finally just 
outside of this membrane a considerable depression in the 
lower wall. This latter is of considerable practical import- 
ance, because small foreign bodies frequently lodge in it, 
and easily escape the observation of the surgeon. 

In the small child the inner half of the auditory meatus 
is really no canal, because the membrana tympani, which 
at this period lies nearly in a horizontal plane, is throughout 
its whole extent in contact with the lower wall of the canal. 
This relation is facilitated by the thickness of the epidermic 
layer of the membrana tympani. 

The lining of the external auditory canal is a continua- 



GLANDS OF EXTERNAL AUDITORY CANAL. 21 

tion of the common integument. In the cartilaginous 
meatus it has considerable thickness, and preserves the 
general characteristics of the skin. It possesses, in old 
people especially, a great number of hairs with their seba- 
ceous glands, the well known ceruminous glands. These 
have the same form, and the same long excretory ducts, 
that are found in the common sudoriferous glands, and 
hence might properly be called the aural sudoriferous 
glands. They are so large as to be visible to the naked 
eye, as small granules of about the size of poppy seeds, and 
lie in the superior layers of the sub-cutaneous cellular 
tissue. They are most abundant in the inner half of the 
cartilaginous meatus. 

On the cadaver, the orifices of the ducts of the sebaceous glands 
can be seen with the naked eye, as fine apertures, especially if the 
macerated epidermis be removed in large pieces. At the same time 
small bulbs will be seen hanging to the epidermis. These are the 
hair follicles and their sebaceous glands. 

Along the upper wall of the osseous meatus there is a 
strip of integument of the same character as in the carti- 
laginous meatus. Externally this strip is quite broad, but 
it gradually becomes narrower, and finally ends in a point 
near the membrana tympani. In the remainder of the 
osseous canal the integument is destitute of subjacent cel- 
lular tissue, of the large hairs and glands, and is thinner 
and smoother ; but it is still made up of separable lamellae, 
and is provided with finer hairs and papillae, arranged 
in regular lines extending to the immediate vicinity of 
the tympanic membrane. Although the integument of 
the osseous meatus is thinner and more delicate it cannot 
be considered a mucous membrane, as has been stated by 
many authors. It is certainly no more than an example 
of the transition stage between mucous membrane and 
external integument, such as is seen in other places where 



22 RELATIONS OF EXTERNAL AUDITORY CANAL. 

the one kind of tissue gradually passes over into the other, 
as at the margins of the nostrils, on the lips, etc. This 
cutis, which becomes gradually thinner as we approach the 
membrana tympani, is so intimately connected with the 
periosteum (the glands and subcutaneous cellular tissue 
being absent) that the latter cannot be easily isolated ; at 
least, it is more easily separated from the bone than from 
the cutis. 

Fig. 2. 







Pr.M/ 



Vertical section of the osseous meatus, right side, close to the membrana 
tympani. M. a. e., external auditory meatus. Cgl. m., articular fossa 
of the inf. maxilla. Squ., inner part of the squamous portion of the 
temporal bone. The dura mater has been removed, and we see the 
prominences and depressions (luga cerebralia et impressiones digitate), 
and superiorly a groove for one of the vessels. F. s., fossa sigmoiaea for 
the sinus transversus. Pr. m., mastoid process, with the outer portion of 
its cellular system. 

In regard to the relation of the external auditory meatus 
to the neighboring parts, it may be said that the cartila- 
ginous portion is bounded anteriorly and inferiorly by the 



RELATIONS OF EXTERNAL AUDITORY CANAL. 23 

parotid gland, and cases have been observed where ab- 
scesses of the parotid have discharged into the auditory- 
canal through the incisurae Santorini. It is evident, also, 
that enlargements of the parotid or of the lymphatic glands 
may contract the canal by pressure. 

The anterior wall of the osseous meatus forms also the 
posterior wall of the articular fossa of the inferior maxilla. 
Hence a blow upon the chin may produce a fracture of 
this plate, and cause a hemorrhage from the ear. The 
comparative infrequency of such results of a fall or blow 
upon the chin are explained by the fact that the thick car- 
tilage of the articulation in question, in a degree, protects 
the temporal bone from the full force of the blow. 

The posterior wall of the osseous meatus is made up by 
the mastoid process in such a way that the canal is sepa- 
rated from the transverse sinus only by two thin plates of 
compact osseous tissue and the air cells lying between 
them. The superior wall is covered on its upper surface 
by the dura mater, and forms a portion of the floor of the 
middle fossa of the skull. This plate of bony tissue, 
lying between the brain and auditory canal, varies in thick- 
ness in different individuals, being sometimes extremely 
thin. It is always provided with open spaces containing 
air, and continuous with the cavity of the tympanic and 
mastoid cells. There sometimes exists but a very loose 
osseous structure between the integument of the meatus 
i and the dura mater ; which fact may be of great practical 
importance, and may explain how inflammations of the 
1 meatus, which are apparently slight, occasionally produce 
i severe and even fatal encephalic disease. Besides it is 
important to fully understand that the meatus is bounded 
superiorly and posteriorly by hollow spaces which belong 
to the middle ear. Thus it is seen that a portion of the 
cc middle ear" lies much external to certain portions of the 
" external ear," e. g., the membrana tympani. The general 



24 BLOOD VESSELS AND NERVES. 

conception is, that the " middle ear," in all its parts, lies 
nearer the median line than the " external ear ; " but this 
is not wholly true. When we come to study secondary 
abscesses of the auditory meatus, and some other cases 
also, we shall again refer to the relation of the air spaces 
of the temporal bone to the external auditory meatus. 

Blood Vessels. — The auditory canal receives its blood 
from the posterior auricular artery (maxillaris ext.), which 
sends branches also to the auricle, and from the deep 
auricular artery (maxillaris int.) which enters at the max- 
illary articulation, supplies the tragus, and distributes 
branches to the inferior, anterior and superior walls of this 
canal. The veins of the external ear, empty in part into 
the temporal vein, a part into the external jugular veins, 
or also into the trunk of the posterior facial vein. 

Nerves. -^-The posterior side of the auricle is supplied 
by several large branches of the third cervical, while the 
anterior side receives branches from the auricularis anterior, 
of the third branch of the fifth. The meatus receives 
one or two twigs from the sensitive auriculo temporalis 
nerve from the third division of the tigeminus ; these 
penetrate its anterior wall, between the cartilaginous and 
osseous sections. The integument receives in addition an 
auricular branch of the pneumogastric or vagus, which 
perforates the anterior wall of the osseous meatus. 

The development of the meatus shows that the pneumo-gastric 
nerve sends a branch to the ear, as well as to the lungs and stomach, 
since the external auditory canal is formed from the first bronchial 
fissure. This auricular branch of the vagus, in the human subject, 
was discovered and first described by Arnold in 1828. 



LECTURE III. 

ANATOMY OF THE EXTERNAL EAR. 

II. Membrana Tympani. 

Importance of a thorough knowledge of the membrana tympani; 
it must be studied on the living subject rather than on the 
cadaver; Rivini s foramen ; arrest of development ; attach- 
ment {sulcus and annulus tympanicus) ; size in the adult 
and in the foetus ; the handle of the malleus ; umbo ; poste- 
rior and anterior pouch ; curvature and inclination of the 
membrana tympani; its color; luster; triangular spot of 
light ; its anatomical structure ; its outer and inner covering, 
and fibrous layer ; vessels and nerves. 

Gentlemen : The membrana tympani forms the parti- 
tion wall between the external auditory meatus and the cavity 
of the tympanum. It belongs to both these divisions of 
the ear; first, by reason of its position, and secondly, 
because the tissues which enter into its composition, and 
because its vessels are derived from both directions. Some 
anatomists have therefore described it under the name of 
middle ear ; but it belongs more properly to the external 
ear, because we find it corresponds to the gill cover and 
integument of the gill cover of fishes, and therefore belongs 
to the surface. 

The examination of the membrana tympani is one of 

I the most essential diagnostic means which we possess in 

diseases of the ear. This is because the appearance of the 

membrana tympani gives us important information in 

4 



26 RIVINl's FORAMEN. 

regard to the state of both the external meatus and the 
cavity of the tympanum, and because it is so easily acces- 
sible to a direct examination. 

It must therefore appear strange that the drum of the 
ear has been so briefly described, even in those text-books 
of anatomy which are considered practical. But the anato- 
mist has not the opportunity to obtain perfectly correct 
and minute knowledge of the ear-drum in all its parts. 
The anatomist obtains his knowledge of this part from ob- 
servations on the cadaver only. But as a description of 
the cornea, according to its appearance some days after 
death, cannot give a correct idea of the properties of this 
organ, so is it also in the case of the ear-drum, which, on 
account of its delicacy, the fact that it is covered by a fine 
layer of epidermis, and the dependence of its curvature 
upon a muscle of striped fiber (the tensor tympani), has 
in the cadaver an appearance entirely different from that in 
the living subject. 

The great errors to which we may be led by the study 
of the anatomy of the membrana tympani, from dried pre- 
parations, are illustrated by the fact, that for two hundred 
years many anatomists have asserted that there was a nor- 
mal opening in the membrane ; when this opening, called 
Rivini's foramen, is nothing more than a rent, occurring 
in the desiccation of the half macerated membrane, as was 
first demonstrated by Hyrtl. 

Rivini's foramen was not first described by Rivinus, professor in 
Leipsic (1689), but had already been described by Glaser (1680), and 
Emanuel Kbnig (1682), professors in Bale, Friedr. Ruysch and Val- 
salva (17 '04) denied the existence of a normal opening in the human 
membrana tympani ; but Berres, Hyrtl's predecessor in Vienna, be- 
lieved in its existence and described it minutely. From the first, 
however, the opening was very differently described ; some authors 
finding it in the center of the membrane, others near its upper border ; 
some describing it as large, others as small. 

1 
! 






ARREST OF DEVELOPMENT. 27 

Quite recently Bochdalek, professor of anatomy in Prague, 1 has 
described Rivini's foramen as a constant opening in the membrana 
tympani ; sometimes, he says, there are two. It is, however, so 
small that its presence is only demonstrable by a magnifying glass, or 
a bristle introduced into it. We should persevere, "for hours" if 
necessary, in attempting to find it, as the discoverer remarks. 

Since, according to Huscbka, the ear-drum is not closed 
at its upper part during the early portion of embryonal life, 
and? is even entirely wanting at first, an opening in it may 
occur from arrest of development, as in harelip or colo- 
boma iridis. 

I have in my possession the petrous bone of a subject in which 
both membranae tympani have an opening at their upper part of about 
3 mm. in diameter. Since both drums have precisely the same ap- 
pearance, and there is no sign of preceding inflammation and ulcera- 
tion, I think it reasonable to infer that the foramina are the result of 
arrest of development. Again, in a young man who had cleft palate, I 
found an opening in the membrana tympani of one ear. This ear was 
in other respects perfectly sound. The opening extended obliquely 
downward opposite the processus brevis mallei. The other ear was so 
much affected by otorrhoea that I could not decide upon the state of 
its membrana tympani. Finally, in the case of an old man, who had 
never had any aural disease, both drums presented at their upper 
border a shallow, rounded depression, about 2 mm. broad, which 
appeared to be caused by an absence, at that place, of the tunica 
fibrosa. After the air douche, the depression became an elevation. 
These states of the membrana tympani, which certainly are but rarely 
observed, are best explained in the manner mentioned above. 

1 Prager Vierteljahrschrift, 1866, I. 



28 ATTACHMENT OF THE MEMBRANE. 

Fig. 3. 




Membrana tympani, as seen from auditory canal. [Gruber. 1 ] 



The membrana tympani, a thin elastic membrane, lies 
at the inner extremity of the external auditory canal, and 
is attached to an osseous groove, the sulcus tympanicus, 
which is only interrupted superiorly. If this groove were 
present above, the method of attachment of the membrane 
might be compared to that of a watch crystal in its case, 
or of a picture in its frame. This attachment is effected 
by means of an annular strip of thick white connective 
tissue, which encircles the outer border of the membrane, 
and, like the sulcus tympanicus, is wanting only at the 
upper part at both sides of the short process of the malleus. 
(Most authors incorrectly call this the annulus carti- 

1 Das Trommelfell, Wien, 1867. 



• 



DIAMETERS OF THE MEMBRANA TYMPANI. 29 

lagineus.) The attachment of the membrane is least firm 
at the upper and posterior portion ; the membrane at this 
point going over immediately into the integument of the 
meatus. This is the point where the membrana tympani 
would be most easily detached by any pressure from inside, 
e. g., by excessive pressure from the air douche. 

The osseous portion which surrounds the membrane 
and encloses the sulcus tympanicus is, in the foetus* a 
detached part of the temporal bone, and is called the 
annulus tympanicus. Its ossification occurs very early, and 
gradually there are developed from it the inferior and an- 
terior walls of the meatus. 

The form of the drum of the ear, like the diameters of the 
osseous meatus, varies in different individuals. In the child 
it is nearly circular, whilst in adults it is more elliptical, 
the long diameter coinciding with the vertical ; frequently, 
however, it is irregularly heart shaped. At the upper part, 
where what was formerly called the annulus tympanicus is 
interrupted, there frequently projects a variously shaped, 
irregular prolongation (about 1 to 2 mm. in hight) into 
the wall of the osseous meatus. 

The different diameters of the membrana tympani are 
also subject to important individual variations. In the 
adult its average vertical diameter is between 9 and 10 
mm., while its horizontal diameter is 8 or 9 mm. In the 
foetus the membrane, in its proportion to the length of the 
body, is much longer than in the adult, since it nearly 
completes its growth during the last month of foetal life, 
and after birth increases at most only in length. 

In order to gain accurate data in regard to the growth of the mem- 
brana tympani in the foetus, I made a measurement of it, in a series of 
skeletons of embryos of from three to nine months. The skeletons 
I found in the anatomical museum at this place. Prof. Kolliker was 
< good enough to make for me an estimate of the age of each, and I 
have added the length of the body in each case. In a foetus of 1 1 



3° 



THE HANDLE OF THE MALLEUS, 



weeks (length of body 56 mm.), the height of the ear-drum was 2 
mm., its breadth 1 \ mm. ; in a foetus of 14 weeks (84 mm.), the 
same diameters 3 and 2 mm. ; in one of 16 weeks (114 mm.), \\ and 
3 mm. ; in one of 20 weeks (155 mm.), 7 and 5J mm.; in one of 
22 weeks (220 mm.), 8 and 7 mm. ; in one of 24 weeks (290 mm.), 
8 \ and 8 mm. ; in one of 7 months (335 mm.), 9 and 8 mm. ; in one 
of 8 months (370 mm.), 8J and 8 mm. ; finally, in one of 9 months 
(450 mm.), 9f and 8J mm. The fact that the longest diameter of 
the foetus of seven months was greater than that of another whose 
length of body was nearly 40 mm. greater, shows that many variations 
may here occur, caused by the different degrees of development of the 
above mentioned prolongation of the superior border of the drum. 

Fig. 4. 




w'/f liMr^ - 

■ - ■ j/fffil 111 • 

7 ijfrd M V > * ' 

!; I [ifv - 




* 



<L 7 



Membrana tympani seen from the cavity of the tympanum. [Gruber.] 

On examining the membrana tympani from the outer 
side, we first notice the handle of the malleus (manubrium 
mallei) , which extends, as a whitish yellow stripe, from the 



THE UMBO. 31 

anterior and superior border downward and backward to 
about its center. This stripe, if prolonged to the inferior 
pole, would divide the membrane into an anterior and a 
posterior half, of which the latter would be the greater. 
At the upper end of the handle of the malleus, just below 
the prolongation of the upper border of the drum, we see 
the processus brevis (abtusus) mallei, or short process, as 
a small, white, rounded tubercle, projecting toward the 
meatus. From the processus brevis the handle of the 
malleus inclines inward toward the cavity of the tympanum, 
the drum being concave outward and convex inward. This 
curvature is greatest at the lower end of the handle ; and 
this most concave portion of the ear-drum, lying a little 
below its center, is called the " umbo," or umbilical con- 
traction of the drum. 

By the "umbo," all the later anatomists understand that point near 
the center of the membrane where the curvature is greatest. Some 
aurists, however, copying many of the older anatomists, describe, 
under " umbo," the projection of the short process of the malleus at 
the upper extremity of the ear-drum. This double use of a term 
causes much ambiguity, and should be avoided. The umbilicus is in 
all cases a depression, except in the new born child, and in the female 
during the later period of gestation. The English, e. g., Toynbee, 
also call the handle of the malleus the long process of the malleus, 
while we understand by processus longus the Folianian process, which 
extends forward into the Glasejjian fissure, and can be seen in children 
only. 

If we now examine the membrana tympani from its inner 
side, we see that the head and neck of the malleus project 
into the cavity of the tympanum. The incus, articulates 
with the posterior surface of the head of the malleus. Its 
long or vertical process lies close to the posterior and upper 
part of the membrana tympani, and behind and parallel with 
the handle of the malleus, without, however, descending so 
far as the latter. Below it we notice a peculiar appendix, or 



32 THE POSTERIOR AND ANTERIOR POUCH. 

supplementary leaf of the drum, which has hitherto escaped 
the observation of anatomists, because it is usually con- 
cealed by the body and long process of the incus. On the 
inner side of the membrane, at the upper part of its posterior 
half, is found an irregularly triangular fold, about 3 or 4 
mm. high, and 4 mm. broad, which arises close behind the 
osseous border to which the membrana tympani is attached, 
and extends to the handle of the malleus. Thus there is 
formed a not inconsiderable cavity, open below, and in- 
creasing in depth from above downward, for which I have 
proposed the name of" posterior pouch, or pocket (Tasche) 
of the membrana tympani." Along the posterior portion of 
the free, concave border of this duplicature runs the chorda 
tympani, which afterwards ascends toward the neck of the 
malleus ; thus leaving below it the deepest portion of this 
duplicature as a small triangle. We obtain the best view of 
this duplicature, and of the pouch formed by it, by viewing 
the drum from the inside, while it is still in its position in the 
temporal bone, and after the pyramid, or at least the entire 
roof of the tympanum, has been removed, and the incus 
detached from its articulation with the head of the malleus; 
hut we can see it from the outer side, and even in the 
living subject when the illumination is good, and the mem- 
brane very transparent.* 

The above described duplicature assists essentially in 
holding the malleus in position. • After it has been divided, 
this bone is much more movable than before. This leaf 
of the posterior pouch consists of the same variety of fibers 
that characterize the lamina fibrosa of the ear-drum. It is 
further shown to be an integral part of the membrane, by 
its origin from the annulus tympanicus, as can be demon- 
strated on the infant, whilst the chorda tympani emerges 
from the bone lying next to the former and genetically sepa- 
rate from it. In the cadaver we often find the two inner 
surfaces of this pocket grown together, either partially or 



POCKETS OF MEMBRANA TYMPANI. 33 

totally, as a result of catarrhal processes in the cavity of the 
tympanum. In this way the normal cavity is either de- 
creased in size or wholly obliterated. 

A similar enclosed space is found in front of the mal- 
leus ; but this anterior pouch of the membrana tympani 
is not formed by a duplicature of the fibrous layer, but 
by a small bony process, turned toward the neck of the 
malleus ; by the mucous membrane which lines every part 
of the cavity of the tympanum, and by all the parts which 
proceed from, or enter the Glaseri fissure; by the long 
process of the malleus, which, as we have seen, is fully de- 
veloped in the child only ; by the ligamentum mallei ante- 
rius, the chorda tympani, and the inferior tympanic artery. 
This anterior pouch or pocket is lower and shorter than 
the posterior. 

These "pouches of the membrana tympani" were first described by 
me in the Wiirzburg Transactions for 1856 (Sitzungsberichte, S. 
XXXIX), afterwards in my tc Contributions to the Anatomy of the 
Membrana Tympani," (Siebold und Kolliker's Zeitschrift fur Wis- 
sensch. Zoologie 1857, IX, B. S. 94). They are noticed in Arnold's 
Icones organorum sensuum (1839), Tab. VI, Fig. XVII. In the text, they 
are called " Plica membranae mucosae anterior et posterior ;" whence 
we infer that he considered them as folds of the mucous membrane 
i only. He did not think them constant, or worthy of further men- 
1 tion, since in all the other illustrations in which the drum is seen from 
■ the inner side, and especially in Fig. XX, Tab. V, where "Mem- 
branae facies interna" is shown after the removal of the incus, 
by which the posterior pocket is made easily visible, they are not 
seen \ nor does he mention them in his text-book of anatomy (1851), 
in which, in other respects, the ear-drum, and in fact the whole audi- 
tory apparatus, is exhaustively described. Henle^ in his text-book of 
systematic anatomy (1866, II, S. 750), describes this supplementary 
leaf of the drum in full, but considers it one of the folds of mucous 
membrane of the cavity of the tympanum. I cannot believe that the 
expression of this opinion was preceded by a microscopic examination 
% of the elements of this part. According to Wildberg ( " Versuch einer 
anatomisch-physiologisch-pathologischen Abhandlung liber die Gehor- 

5 



34 CURVATURE OF MEMBRANA TYMPANI. 

werkzeuge des Menschen," Jena 1795, S. 95), it appears that the older 
anatomists were acquainted with this duplicature of the drum, and con- 
sidered it a muscle, (muse, mallei superior, also called laxator tympani 
minor). Prussak has lately described an upper pouch or pocket, 
whose outer surface is formed by the above named membrana flaccida, 
and the inner by the outer surface of the neck of the malleus, and 
which is only seen posteriorly above the posterior pocket. 

If we now study more closely the curvature and the in- 
clination of the drum, we remark, first of all, that although 
the membrane, as a whole, is made concave externally by 
the traction of. the malleus, it still normally curves some- 
what forward in some parts. 

Thus the anterior and lower part, from the umbo to the 
border, presents a pretty well developed convexity out- 
ward ; besides, the short process of the malleus produces, j 
at the upper pole of the ear-drum, a small but very decided 
bulging, from which there frequently proceed two folds, 
the shorter running forward, the longer running backward. 

The inclination of the membrana tympani is also some- 
what difficult to understand. The membrane is placed 
obliquely at the end of the auditory canal, obliquely in 
two senses; that of its vertical, and that of its horizontal 
diameter. In this way it forms with the lower and anterior 
wall an acute angle, but with the upper and posterior wall 
an obtuse angle. The anterior border of the membrane is 
farthest removed from the outer extremity of the canal, 
the lower border next, then the posterior, and finally the 
upper border. If a perpendicular be drawn from the upper 
pole of the drum it will meet the lower wall of the auditory 
canal at a point about 6 mm. from the lower pole of the 
membrane. The peculiar obliquity of the drum, is deter- 
mined by the varying length of the different walls of the 
auditory meatus ; that is, by the inclination of the osseous 
ring, bounding the auditory canal internally, in which the 
membrana tympani is inserted. 



POSITION OF MEMBRANA TYMPANI. 35 

This osseous ring, which for a long time possesses a 
certain independence, forms however an integral part of 
the base and lateral wall of the skull. Hence the fact is 
explained, that its position and inclination depend, to a 
certain extent, upon the existing degree of development of 
the whole skull, whether the completion of this develop- 
ment proceeds according to the laws of physiological 
growth, or is subjected to morbid disturbances and ar- 
rests. 

In the foetus, the annulus tympanicus and the ear-drum 
lie quite horizontally, forming a portion of the base of the 
skull. Even in the new born child the membrane has a 
nearly horizontal position, and forms, with the upper wall 
of the meatus, nearly a straight line. The upper pole of 
the drum must therefore, in the new born, be properly 
called the lateral pole ; and it lies pretty near to the outer 
extremity of the meatus. This horizontal position of the 
membrane in small children makes the difference between 
the length of the lower and that of the upper wall very great. 
Indeed, the lower wall is twice as long as the upper, of which 
the membrana tympani is the continuation. As the skull 
becomes developed, the membrane gradually approaches a 
vertical position. Still its inclination in the adult is sub- 
ject to great individual variations, which probably depend 
not only upon the position of the squamous portion of 
the temporal bone, but also upon the lateral and longi- 
tudinal development of the base of the skull ; so that we 
can, perhaps from the degree of inclination of the mem- 
brane of the living subject, decide in regard to the higher 
or lower portion of the sphenoid bone, and the history of 
development of the skull in general. The best ♦measure 
of the degree of inclination of the drum is given by the 
angle which it makes with the upper (or with the posterior) 
■ wall of the canal ; and this is, perhaps, also the easiest 
way of obtaining it. A series of measurements on the 



36 INCLINATION OF MEMBRANA TYMPANI. 

normal ears of adults gave an average of 140 for the 
angle above mentioned. 

Bonnafont and Schwartze found a very striking vertical position of 
the membrana tympani in musicians. I may add to this, that in 
persons with no musical taste, the very oblique position of the mem- 
brane was marked. A. Feck 1 has shown that the membrana tympani 
cannot be so much put in motion by vibrations of sound with its 
oblique position, as would be^the case if it were perpendicular to the 
auditory canal. 

In a deaf mute of 35 years of age, who was reported to be a cretin, 
the membrana tympani formed an angle of 167 with the upper wall 
of the meatus ; about the same as that of a child. Since I possessed 
the middle portion only of the base of the skull, I could make no 
estimate of the clinoid angle, nor form any opinion in regard to synos- 
toses, and arrests of development in the base of the skull. (Voltolini 
also found, on dissection, a nearly horizontal position of the drum in 
two deaf mutes. One subject was 16 and the other 17 years of 
age. 2 ) That the degree of the angle of the drum should remain, in 
such cases, equal to that of the child is something very striking ; 
however, Virchow has already shown, in his classical investigations 
in regard to cretinism, and the development of the base of the skull, 
that a certain relationship exists between cretinism and deafmutism. 
(In order to decide whether this position of the ear-drum is constant 
in cretins, I examined all the skulls of cretins that are to be found in 
the institution at this place, but found them untrustworthy from the 
maceration and drying which the skulls had undergone ; but the 
results which I did obtain, although uncertain, incline me to the 
opinion that this position is constant.) 

The measurement of angles in those parts to which we cannot 
directly apply the quadrant, or of which we cannot obtain good sec- 
tions in profile, is very laborious. It can best be made by drawing a 
whole system of parallel lines, and determining from them the angle 
in question. Quite recently I have been enabled to estimate, with 
great easo, the angle of the membrana tympani by means of a simple 
and ingenious apparatus, which William Hess, teacher of mechanics in 
the Gewerbschule, of Wiirzburg, contrived especially for this purpose. 

1 Anatomie und Physiologie der Sinnesorgane, Lahr 1864, S. 135. 

2 Virchow's Archiv, B. XXII, S. 127, and B. XXXI, S. 212. 



COLOR OF MEMBRANA TYMPANI. 37 

The normal membrana tympani is very thin, about as 
thick as very fine letter paper, or gold beater's skin. 
According to Henle it is about o.i m. in thickness. This 
delicacy causes it to be transparent, and makes it very liable 
to perforation. It is also quite elastic, so that it will bear 
considerable pressure, either from within or without, with- 
out rupturing. 

The color of the membrana tympani must be studied 
on the living subject; the statements of anatomists in 
regard to it are of doubtful value. On the cadaver this 
part is dull, whitish and opaque, on account of the loosen- 
ing and maceration of the epidermic layer; on the living 
subject it is lustrous, pearly gray, and translucent. 

We shall here follow the excellent descriptions of Po- 
litzer. 1 " First of all, we must consider that the drum is 
a so called translucent medium, which reflects a portion of 
the light thrown upon it, but allows another portion, suf- 
ficient to illuminate the tympanum, to pass through it. 
From the promontory on the opposite wall of the tym- 
panum a portion of this light is^ reflected, which again 
traverses the membrana tympani with some loss, and 
reaches our eye. The color of the drum is therefore one 
of combination, made up of the proper color of the mem- 
! brane, that of the light used for the examination, and of 
the quantity and color of the rays which reach us from the 
promontory. In those cases in which we describe the 
I membrana tympani as of normal appearance, we can com- 
\ pare the color of the membrane, as seen by ordinary day- 
' light, to a neutral gray, with the addition of a weak tone 
i of violet, and light brownish yellow." 

The thinnerand more transparent the membranatympani, 
and the less its obliquity, and the smaller its distance from 
the parts of the cavity of the tympanum, the more influence 

1 Beleuchtungsbilder des Trommelfells im gesunden und kranken Zustande, Wien, 1865, 
S. 14. 



38 COLOR OF MEMBRANA TYMPANI. 

will the latter exercise upon the color of the membrane ; 
in other words, the more will light reach us from them. 
Thus, we often see the middle of the membrane, the umbo, 
and the point immediately back of it, appearing yellowish 
gray, in consequence of the reflection from the promontory; 
so, also, the long crus of the incus behind and parallel to 
the handle of the malleus, although not reaching so far 
down as the latter, may often be seen as a faint yellowish 
gray line, from the extremity of which a thinner line runs 
backward and upward. This latter is the posterior crus 
of the stapes. (These appearances are most frequent in 
cases of chronic closure of the Eustachian tubes, or when 
an individual, with a very transparent membrana tympani, 
swallows several times with the mouth closed and nose 
stopped. In both cases the air in the tympanum is rarified, 
and the drum pressed in.) 

But the color varies in different parts of the membrane. 
The gray color is generally darkest in front of the handle 
of the malleus, and above the triangular light spot, to be 
soon described, whilst this color is lighter at the posterior 
half of the membrane. In not a few cases, the upper part 
of the posterior half appears whitish gray, and is bounded 
inferiorly by a line running backward from the handle of 
the malleus. This line is the chorda tympani, and this 
portion of the membrane is that behind which is placed the 
supplementary leaf of the membrana tympani. 

The gray of the drum becomes mixed with a greater 
or less amount of red when its mucous membrane, or that 
of the whole cavity of the tympanum is injected. The 
membrane appears more or less yellow when there is a 
secretion of this color in the tympanic cavity. Bubbles 
of mucus on the inner surface of the membrane can be 
sometimes very easily seen. In pathological cases the color 
of the drum undergoes the greatest variations, and we 
may find all the shades of white, gray, yellow and red. 



TRIANGULAR LIGHT SPOT. 39 

In the membrana tympani of the child, the covering 
derived from the integument of the meatus is thicker than 
in the adult. This is also true of the mucous membrane 
of the cavity of the tympanum. Hence, as a rule, the ear- 
drum of the child appears thicker and of a darker gray, and 
the promontory is but rarely seen through it. In old age, 
it again becomes duller, less translucent and whiter. 

The delicate luster of the outer surface of the membrane 
depends upon the thinness of the layer of epidermis, so 
that it is lost so soon as the epidermis becomes thickened, 
swollen or macerated. This loss of luster, is constant in 
cadavers where the epidermis of the ear-drum is changed by 
maceration, in the same manner as in the cornea. In cases 
where water, oil or other fluid has been poured into the 
ear, the surface of the membrane then appears more or 
less dull, the epidermis swollen and sometimes partially 
detached, as in alcoholic preparations. In some cases, 
where the ear-drum is drawn strongly inward, its luster is 
increased and the membrane, as a whole, appears more 
strongly stretched. 

In the normal membrana tympani, in .addition to the 
bright luster extended over its whole surface, there is 
always one spot where the light is more strongly reflected. 
This spot is found in the anterior inferior quadrant of 
the membrane, and has the form of an isosceles triangle. 
Its base (i J-2 mm. in length) is nearly at the border of the 
drum and its apex at the umbo, a little before and below 
the end of the handle of the malleus. This triangular 
light spot (with German authors, Lichtkegel, cone of light) 
may be compared, in its appearance, to the reflection from 
the cornea. It is so situated as to make an acute angle 
with the course of the handle of the malleus. This re- 
flexion is usually broader when the ear-drum is pressed 
outward, and smaller when it is pressed inward by artificial 
rarefaction of the air in the cavity of the tympanum. 



40 TRIANGULAR LIGHT SPOT ON DRUM. 

* 

This triangular light spot, is varied in appearance so soon 
as there is any abnormal change in the surface or curvature 
of the membrana tympani. This very frequently occurs 
without any noticeable impairment of hearing, and anomalies 
of the spot of light, are not unfrequently seen in people who 
hear well. Sometimes the reflection is longitudinally di- 
vided into two parts, or there may be a space between the 
apex and base when no light is reflected. Sometimes it is 
contracted to a narrow line, or its apex or base, may be 
indistinct or wanting, so that finally it may be reduced to 
a rounded point. Of course this reflection is but weak, or 
is absent when there is a general loss of luster of the 
ear-drum from derangement of the delicate transparent 
cells of epidermis which cover the outer surface of the 
normal membrana tympani. 

Wilde, of Dublin, who first described this reflecting portion of the 
membrana tympani under the name of " speck of bright light/' attri- 
buted it to the convexity of the anterior half of the drum. The 
objection to this view is the fact, that the reflection takes place not 
only at that part which is convex outward, but also at the umbo, the 
most concave portion of the drum. The most thorough investigations 
in regard to the causation of this reflection have been recently made 
by Politzer. 1 According to this author, the principal cause lies "in 
the inclination of the membrane to the axis of the auditory canal, in 
connection with the concavity of the drum, caused by the traction of the 
handle of the malleus. " Politzer used in his experiments a preparation 
of the auditory apparatus which he had cautiously dried, and from which 
he had removed the external meatus, leaving the membrane attached 
to the ring of bone around it. If the preparation were now so turned 
that other portions of the drum occupied the place formerly held by 
the spot of light, every one of them showed a reflection of light which 
varied more or less from the usual spot of light. Politzer continues : 
" What, then, are the conditions under which this reflection of light is 
effected ? If the membrana tympani were a plane surface, and retained 

i Archiv. fur Ohrenheilkunde, I, p. 155, and " Beleuchtungsbilder des Trommelfells," 
p. 24. 






HISTOLOGY OF MEMBRANA TYMPANI. 41 

its present inclination to the auditory canal, there would be no reflec- 
tion to be seen ; since, according to the laws of reflection, the light 
would be thrown toward the anterior and lower wall of the auditory 
canal. By means of the curvature of the drum, however, portions 
of the membrane are so changed in position that the light reflected 
from them is reflected to our eye. One can easily convince himself 
of the correctness of this opinion by stretching a glistening organic 
membrane over a large ring, and giving it the inclination of the drum 
of the ear. If we then examine it with the mirror, as we examined 
the membrana tympani, we find no reflection ; but so soon as the 
central portion of the membrane is forced inward by pressure or trac- 
tion, we shall find a reflection occupying a position corresponding to 
that of the spot of light in the membrana tympani." 

Turning to the minute anatomy, the histology of the 
membrana tympani, we find that the membrane consists of 
three layers, viz. : a middle, fibrous layer (lamina propria 
or fibrosa membranae tympani), and the coverings which 
this receives, on its outer surface from the integument of 
of the meatus, and on its inner surface from the mucous 
membrane of the cavity of the tympanum. 

The outer covering of the membrana tympani consists 
not only of epidermis, but also of elements of the cutis, 
derived from the integument of the meatus. These ele- 
ments are found over the whole membrane, so that the 
connective tissue beneath the epidermis is continuous 
with the connective tissue of the cutis of the external 
meatus. These cutis elements are, however, shown to be 
most abundant at the upper part of the membrane, where 
quite a strong bundle proceeds from the wall of the meatus 
to the ear-drum. A close examination shows that this 
consists of connective tissue with many elastic fibers, of 
several vessels, and of a comparatively large nerve twig. 
This bundle descends along the handle of the malleus to 
the umbo, whence it spreads out in a radiate direction. 
The more complicated elements of the cutis, as also pap- 
6 



42 LAYERS OF MEMBRANA TYMPANI. 

illse and glands, are wholly absent in the outer covering 
of the membrana tympani. This covering is found at its 
greatest degree of development in children. 

In the cadaver, the epidermis of the membrana tympani may gene- 
rally be removed in uninterrupted connection, and, after prolonged 
maceration, we can frequently take it away with the cuticle of the 
meatus ; the two together forming a tube, closed at one end. This 
layer consists of several laminae of epidermoidal elements ; the outer 
elements resembling irregular corneal plates, the inner ones being 
polyonal, nucleated cells. In children, we frequently find this layer 
of abnormal thickness ; and under the hard, external portion, several 
Jayers of cylindrical, or fusiform cells, corresponding to the epider- 
moidal structure of earlier date. The above mentioned bundle which 
conveys the vessels, nerves and cutis elements, for the most part, to 
the surface of the drum may be followed for some distance along the 
upper wall of the meatus. It was formerly described as the musculus 
laxator tympani minor, and is still sometimes called the ligamentum 
mallei externum. 

The inner covering, a continuation of the mucous mem- 
brane of the cavity of the tympanum, consists usually of a 
simple or manifold layer of non-vibratile tesselated epithe- 
lium, beneath which there is a very thin layer of cellular 
tissue at the extreme border only of the membrana tym- 
pani. This mucous lining in the normal state is of extreme 
thinness, but it is very frequently subject to pathological 
changes, and then is often considerably thickened. In the 
peripheral portion of this layer of mucous membrane 
Gerlach 1 observed a considerable number of "peculiar pro- 
jections/' which may be regarded either as papillae or as villi. 

These projections are found "in the outer third of the lower, and 
in the outer two-thirds of the upper half of the membrana tympani." 

i " Mikroscopische Studien aus dem Gebiete der menschlichen Morphologie," Erlangen, 
1858, p. 61, with illustrations of these villi in Tab. VIII. In regard to the histology of the 
ear-drum, see also Toynbee, Philos. Transactions, 185 1, I, p. 159, and v. Troltsch, in the 
Zeitschr. fur wissensch. Zoologie, 1857, B. IX, S. 91. Also J. Gruber and Prussak. 



LAYERS OF MEMBRANA TYMPANI. 43 

Some of them are spherical, like the sponge-shaped papillae of the 
tongue ; some are simply finger shaped prolongations of the mucous 
membrane, like the villi of the intestines. The first reach a very 
considerable size, and, with good illumination, can be seen with the 
naked eye. Their diameter is from o.io to o.i2 //r , and their length 
0.12 to 0.14/". The finger shaped projections are smaller; 0.10 to 
o.i2 //r long, and 0.06 to o.o8 //r broad." 

" The central portion of these projections consists of common 
connective tissue, containing one or more capillary loops. In the 
periphery of the projections this connective tissue appears more homo- 
geneous and, like the mucous membrane, is covered with several 
layers of flattened epithelial cells. I have looked in vain for nerve 
fibers in these structures, and am therefore inclined to class them 
with the villi rather than with the papillae. This view is also favored 
by the fact that some of them are connected with the mucous mem- 
brane by pedicles." Gerlach. 

The middle, fibrous layer, the lamina propria, of the 
membrana tympani, consists of fibers peculiar to itself, 
partly radiating, partly circular, yet so arranged that they 
form two easily separable layers, each of which contains 
fibers of only one direction. 

The outer of these layers (the layer of radiating fibers) 
consists of fibers which run from the cartilaginous ring to 
the handle of the malleus ; the fibers of the lower half 
having their center in the scoop-shaped end of the handle 
of the malleus, whilst the other fibers are attached to its 
anterior ridge. 

The radiate character of this layer is not effected by a direct radiate 
- arrangement of its individual fibers, as would be inferred by an exam- 
ination by a low power ; but their resultant is radiating, by the 
t crossing of fibers which come obliquely from the two sides. This 
arrangement of the fibers makes the highly magnified image appear 
somewhat rhombic. 

The inner layer (layer of circular fibers) consists of con- 
centrically arranged circular fibers, which are wanting in 



44 LAYERS OF MEMBRANA TYMPANI. 

the extreme periphery, are most abundant just inside the 
periphery, and thence gradually decrease in number toward 
the center. When these circular fibers are most strongly 
developed they form a pretty well defined ring ; the thick- 
ness of this layer, according to Gerlach, being twice as 
great as that of the radiating fibers. This layer of circular 
fibers is very intimately connected with the mucous mem- 
brane ; the nutrition of the former being dependent upon 
the latter. 

We can often see this double direction of these fibers 
with the naked eye, by holding the membrana tympani 
between the eye and the window. With a microscope of 
low power this can be seen more easily. To demonstrate 
the two fibrous layers, it is best to manipulate the prepara- 
tion under water with the aid of two forceps. It is evident 
that the membrane is materially strengthened by this ar- 
rangement of its fibers. 

The handle of the malleus lies between these two layers, 
or rather the one proceeds from it, and the other lies behind 
it; but in such a way, that the upper portion of the ring 
of circular fibers runs along the anterior side of the neck 
of the malleus. 

Joseph Gruber and Prussak have recently made some thorough in- 
vestigations as to the relations of the handle and short process of the 
malleus to the membrana tympani, which have given us some new 
points of view of this important question. 

Gruber first called attention to a cartilaginous structure, beginning 
above the short process, and running along the handle of the malleus, 
and has recently described it in his monograph on the membrana 
tympani. (The plates of the membrana tympani, on pages 28 and 
30, are from this work. St. J. R.) 

Gruber states that there is a complete articulation between this 
cartilaginous structure and the malleus ; that they are separated by an 
epithelial layer, and that there is synovial fluid between them. 

Prussak^ on the contrary, denies that there is any separation 
between this cartilage and the malleus. He states that there is not 






LAYERS OF MEMBRANA TYMPANI. 45 

only a coating from the cartilage to the short process and the malleus, 
but that the cartilage enters into the substance of the malleus. Thus 
the cartilage forms another portion, and not unfrequently one-half of 
the whole size of the short process. On the handle, also on section, 
cartilage cells were found not only in the periphery but in the interior. 
According to Prussak, only the membrana flaccida lies in front of the 
neck of the malleus, in which there are no decided fibers. The cir- 
cular fibrous layer surrounds the lower third of the malleus on all 
sides ; so that it lies, as it were, buried in this layer. The higher up 
we make the section, the greater will be the amount of circular fibers 
formed on the outer surface of the malleus, and the less of them on 
the inner side. The circular fibrous layer thus plays the part of 
periosteum and of perichondrium for the handle and short process of 
the malleus. 

According to Gerlach, the layer of radiating fibers spring, for the 
most part, from the annulus tendineus. The layer of circular fibers, 
on the contrary, begins in the peripheral portion of the ear-drum. 

Both portions of the fibrous layer of the membrana tym- 
pani consist of sharply defined, ribbon shaped, homogeneous 
fibers of high refractive power, and of peculiar kind. Be- 
tween them, in regular arrangement, lie fusiform, nucleated 
cells, provided with several processes and corpuscles of cel- 
lular tissue, which, in the two layers, are differently arranged, 
both in respect to the position of the corpuscle and the 
direction of the processes. Microscopic sections of the 
ear-drum give a fine picture of a tissue traversed by a 
delicate cellular net, with its ramifications in all directions. 
This appearance is even more beautiful than that which we 
observe in sections of tendons or of the cornea. 

In the newly born, these fibers are much narrower, and resemble 
curled connective tissue, since they are less highly refractive than in 
the adult. The interstitial cells appear in extraordinary abundance 
on the addition of acetic acid. 

The membrana tympani histologically bears a great resemblanee 
to the cornea ; and many of the descriptions and drawings of ulcera- 
tions and other pathological conditions of the cornea, as His and 



46 VESSELS OF MEMBRANA TYMPANI. 

others give them, often correspond to the appearance under the micro- 
scope of similar changes in the membrana tympani. 

In sections of the membrana tympani of the child, which are the 
most serviceable in studying the cellular constituents of the lamina 
fibrosa, I several times found a constant relation between the cor- 
puscles of cellular tissue and the epithelium, so that it appeared as if 
the epithelium of the inner surface of the ear-drum sent processes 
into the proper tissue, or as if the ramifications of the corpuscles of 
cellular tissue stood in direct connection with the epithelial cells. 

In regard to the perfectly homogeneous connective tissue, 
which makes up the fibrous layer, Gerlach says : cc It holds 
an intermediate position between the fibrillated and the 
homogeneous connective tissue of Reichert. Perhaps its 
study will most readily bring the much talked of connective 
tissue question to a solution. Not the slightest trace of 
fibrils, which would characterize them as bundles of con- 
nective tissue, can be demonstrated in these fibers. ,, 

Vessels of the Membrana Tympani. — This membrane 
possesses two sets of vessels, coming from distinct sources 
and, according to Gerlach, having no connection with each 
other, except at the periphery by capillary anastomoses. 
The external vessels are found in the layer of cutis, that 
connective tissue which lies between the deep cells of the 
epidermis and the layer of radiating fibers. The inner 
vessels lie in the mucous membrane of the membrane, the 
fibrous layer being wholly destitute of vessels. 

The external vascular net work of the ear-drum arises 
from the vessels of the cutis of the meatus (these arising 
from the art. auricularis profunda of the maxillaris int.). 
The vessels of the cutis are continued to the surface of the 
drum in the same manner as from the cutis itself, as de- 
scribed above. 

This occurs on the whole circumference of the mem- 
brana tympani, where they form a fine centripetal circle of 
vessels, which are generally found injected with the adja- 



NERVES OF MEMBRANA TYMPANI. 47 

cent deepest part of the auditory canal. These little 
vessels are nevertheless quite fine, and their injection is 
more rarely observed. Some larger vessels extend them- 
selves from the upper wall of the auditory canal upon the 
membrana tympani, and these run immediately above the 
handle of the malleus, or a little behind it, to the umbo, 
to the middle of the membrane, whence they finally branch 
off in a radiate direction towards the edge ; and in that 
place unite with the peripheric vascular net work. These 
larger vessels are very frequently filled with blood on the 
dead body as well as in the living subject. Their vascu- 
larity appears under our very eyes, if we inject warm water 
in the auditory canal, or if the patient inflates the mem- 
brana tympani. Not unfrequently they fill up with blood 
of themselves, from an examination with the speculum, 
which has been continued a long time, or which has been 
often repeated. 

The inner vascular net work of the membrana tympani, 
running in the mucous membrane, arises from the vessels 
of the tympanic cavity, but is smaller than the outer ves- 
sels, which have a superficial course. It is very difficult 
to preserve successful artificial injections of the membrana 
tympani. 1 However, we frequently find on the dead body, 
especially on dead bodies of children, very instructive 
natural injections of the larger vessels of the one or of the 
other part. We may also convince ourselves very easily 
on the living subject, that the chief vessels of the tym- 
panum, which run superficially along the handle of the 
malleus, proceed from without, that is, from the upper wall 
of the auditory canal. 

Nerves. — As the cutis is the most vascular part of the 
membrane, so the nerves are chiefly or wholly found in 
this structure. Quite a large nerve trunk branches out on 

1 Such an one is described in Rudinger's Atlas (Miinchen, 1866), Table IX. 



48 NERVES OF MEMBRANA TYMPANI. 

it. This tympanic nerve, exactly like the principal vessels, 
passes from the integument of the upper part of the wall 
of the auditory canal, over upon the membrana tympani. 
At the short process of the malleus, little branches are 
given off, which run along the handle of the malleus some- 
what above or behind it, very superficially, up to the 
extremity of the long process or handle. We may still 
often follow it, in fine twigs under the handle of the mal- 
leus. 

This tympanic nerve is a branch of the superficial tem- 
poral nerve, or the auriculo temporal, a sensory branch of 
the third branch of the 5th, and causes the very great sen- 
sitiveness of the outer surface of the membrana tympani. 
I once found a nerve twig passing from the auditory canal 
upon the lower and posterior part of the membrana tym- 
pani. I have never been able to find nerve filaments, either 
in the fibrous or mucous layer of the drum. Gerlach has 
observed fine nerve fibers, without medulla, in the latter. 
At any rate, the mucous layer has very few nerves, while 
the cuticular layer has very many, and is very sensitive. • 

This fact coincides with the practical experience, that 
superficial inflammations of the membrana tympani are 
always very painful, while the greatest changes may take 
place in the mucous layer without the patient ever having 
any pain in the ear. 

We may easily convince ourselves of the just described course of 
the tympanic nerve, by separating the integument of the osseous por- 
tion of the auditory canal, and then dissecting up in connection with 
it, the outer layer of the membrana tympani, and treating it with a 
solution of soda. The principal branch is so large, however, that 
we may frequently follow it with the naked eye, or a magnifying 
glass, some distance on the outer side of the membrana tympani. 

The chorda tympani nerve, although it runs on the 
inner surface of the membrana tympani, gives off no 
branches to it. 






LECTURE IV. 

DISEASES OF THE AURICLE. 

Contusions ; othatomata ; incised and other wounds; tumors; 
acute and chronic eczema ; the auricle in the gouty diathesis; 
malformations. 

Gentlemen : In beginning to-day, to speak of the dis- 
eases of the outer division of the ear, we have first to 
describe the affections of the auricle. This description 
need not, however, consume much time, since the auricle 
is comparatively seldom alone affected ; and when it par- 
ticipates in affections of the surrounding parts, there are 
usually no very peculiar symptoms. 

Injuries of the auricle not unfrequently occur, on account 
of its exposed position on the side of the head. The most 
frequent are contusions from a blow or a fall. If, on the 
receipt of such injuries, the skin be not at the same time 
divided, the blood becomes extravasated between the in- 
tegument and the cartilage on the concave surface of the 
auricle, and fills up its depressions, or causes the previously 
sinuous portions to appear as roundish elevations or swell- 
ings. Such tumors, which are usually of a bluish red 
appearance, having a doughy feel, exhibit in recent cases 
an increase of temperature, and are generally developed 
in the upper half of the auricle, whose whole appearance 
is completely changed by the extravasation of the blood. 
If the cartilage itself has been affected by the injury, or if 
complete resorption of the extravasated blood has not 

7 



50 OTHATOMATA IN THE INSANE. 

occurred, characteristic changes in the shape of the part 
are apt to remain. In consequence of the thickening of 
the soft parts, and subsequent cicatritial contraction, the 
long and short diameter of the auricle become somewhat 
shortened, and more curved in some parts, while in 
others it is folded together, causing an obliteration of 
the different normal depressions and elevations, so that 
the part assumes a peculiar, as it were, a shrunken or 
shriveled appearance. This deformity, which occurs most 
frequently on the upper part of the auricle, may be some- 
times observed on fhe ears of boxers, and also as a plastic 
ornament on antique statues of pugilists and gladiators, 
as well as on those of the deities, such as Hercules and 
Pollux, who were renowned for their fighting powers. 

Othatomata. — The vascular tumor of the ear, occurring 
in the insane (othatoma), is quite similar in appearance 
and course to the form first spoken of, arising from extra- 
vasation of blood caused by contusion. Most of the 
modern physicians for the insane, believe that these otha- 
tomata have a mechanical and traumatic origin, and that 
they are not peculiar to the insane. They are found very 
frequently in the ears of the insane, and especially of 
maniacs and paralytics, because these injure themselves 
much more frequently than the other classes, and are much 
exposed to injury from their surroundings. Gudden has 
been the most exact observer as to this point. 

Virchow 1 and Ludw. Meyer' 1 have recently shown, that 
even after very considerable injuries to the ear, no such 
tumors occur, and that they appear in cases where it can 
be proven that only a slight stretching of the auricle has 
occurred. A normal auricle is. said to have great capa- 
bility of resisting injuries of any sort. We must hence 
believe, where rupture of the cartilage and blood extrava- 

i Die Krankhaften Geschwulste I, Berlin, 1863, S. 135. 
2 Virchow's Archiv., XXXIII, S. 457. 



WOUNDS OF AURICLE. 5 I 

sations have occurred, that there is some morbid property 
in the tissue of the part. Virchow speaks of old softening 
processes as such predisposing causes. L. Meyer speaks of 
enchondromatous degeneration and tissue proliferation of 
the auricle, by which alteration of structure occurs, and 
the elasticity of the part is diminished, and thus the occur- 

I rence of extravasations and ruptures is considerably favored. 
Such tumors of the auricle, having in part bloody and in 
part albuminous contents, have been observed in cases 
where no mechanical force has been applied to the ear ; a 
fact which speaks for the correctness of the idea of Virchow. 1 
It is very natural, however, that very frequent and vio- 
lent maltreatment of the ears, for example, such as occurred 

1 to ancient as well as modern pugilists, should gradually 
produce such a degeneration of the cartilaginous tissue, as 

! will finally lead to its rupture and to hemorrhages. 

There are also very different views as to the treatment 
of othatomata. Some authors advise the evacuation of 
the effused blood by extensive incisions ; while others 
assert, that after such incisions the tumor fills up again 
rapidly, and thus retards the healing, and that the de- 
formity remaining will be greater than if the matter has been 
left to itself. Others recommend the insertion of setons. 

Wounds. — There is nothing of especial interest in wounds 
of the auricle. I only mention them here, because, as is well 
known, they are among the more frequent of the affections 
of students. (In allusion to the results of student's duels, 
so common in some German universities.) 

On account of the irregularity of the surface of the 
wounded part, which renders it rarely possible to use adhe- 
sive plaster, the cut surfaces must be united by suture. 
Auricles which have been entirely divided will heal again. 
In India, where, as is well known, the ears are sometimes 

i Chimani, Archiv. fur Ohrenheilkunde II, S. 169, Schwartze, ibid., S. 213. 



52 TUMORS OF AURICLE ECZEMA. 

cut off in war, and as a punishment for crime, they are said 
to be sometimes replaced by a transplantation from a living 
person. With us, artificial ears are usually made a sub- 
stitute for those which are lost. The hearing power does 
not appear to suffer markedly from loss of the auricle, as 
many observations have shown. 

Tumors. — Among the tumors which occur on the auri- 
cle, there are, besides the various sorts of sebaceous tumors, 
and an unfrequently observed hypertrophy of the auricle, 
roundish growths with hard fibers, which sometimes occur 
as cc a punishment for the barbarous custom of wearing 
ear rings." They develop from an improperly treated punc- 
ture of the lobe of the ear, attain a considerable size, and 
should be removed with the knife. 

These slowly growing fibroid tumors of the auricle are 
said to be very common among the negroes of the Antilles. 
[They are not uncommon in New York, especially among 
the colored females, although I have removed several from 
whites. Brass ear rings have generally been worn when 
these growths occur. A V shaped incision, including the 
tumor, made with strong scissors, is the best method for 
their removal, and one which enables us to restore the nor- 
mal appearance of the lobe to a surprising extent. St. J. R.] 
Erectile and other vascular tumors have been observed on 
the auricle, and have been removed. Epithelial cancer of 
the auricle also occurs not unfrequently. 

Eczema. — It is not unfrequently observed that acute and 
chronic eruptions of the integument, of the most diverse 
character, are continued from the neighboring parts upon 
the auricle. Eczema of the auricle is one of the most 
common of the affections of the skin, which thus localize 
themselves. 1 

i A very extended account of this affection are to be found in Archiv. fur Ohrenheilkunde 
I, S. 133, by H. Auspitz. 



CHRONIC ECZEMA. 53 

The disease is in general characterized by the same pe- 
culiarities as those seen in eczema of other parts of the 
body. Yet there are always some variations in the course 
and symptoms, which are due to the peculiar structure and 
the properties of the auricle. 

Eczema appears on the ear either in an acute or chronic 
form. Acute eczema is chiefly indicated by a great redness 
and edematous swelling of the skin, so that the auricle 
generally stands out quite prominently from the head. 
There are numerous vesicles arranged closely together, 
which burst at intervals and throw out an abundant reddish 
colored fluid, which runs down over the lobe of the ear. 
In the very severe forms, we are not able to distinguish 
individual elevations of the epidermis, with serous con- 
tents, but we find the surface greatly reddened and infil- 
trated with a consistent fluid. The subjective symptoms, 
united to these objective ones, are a sensation of great heat 
in the part, and painful tension, occasionally accompanied 
by febrile excitement. 

Eczema of the ear is more frequently observed as a 
chronic disease. We then have either the impetiginous 
form, when the fluid, exuded in various points, dries up 
quickly and thus causes the formation of yellow or yellowish 
brown crusts, or an abundant development of epidermis on 
a reddish base occurs, in conjunction with some moist spots. 
[Eczema squamosum^ — In this latter form especially, in 
consequence of the scratching of the patient, occur excoria- 
tions and deep slit like fissures, rhagades^ upon which the 
epidermis is destroyed, and between whose red edges an 
abundant fluid generally exudes. 

Chronic Eczema. — This is most frequently seen in con- 
nection with eczema or seborrhcea of the scalp. The 
whole integument of the ear takes part in some way in the 
inflammation or only individual parts may be affected. 



54 CHRONIC ECZEMA. 

Thus, at times, only one fissure is formed on the posterior 
surface where the auricle is united to the mastoid process, 
or there is a denuded portion, surrounded by small crusts, 
in the depression behind the helix. In other cases, the 
lobe alone is of reddish color, moist, or covered with 
scales ; and then the eczema always starts from the per- 
foration that is made for the insertion of an ear ring, in 
case such exists. 

Eczema appears to occur most frequently in children, 
and females in the climacteric periods, puberty, and cessa- 
tion of the menses. It is then often very obstinate, and 
frequently relapses. On account of the severe itching and 
burning sensations, and the long duration of the disease, 
which may be for years, and the fact that it causes a de- 
formity of the auricle, it may become a very unpleasant 
affection. The auricle, naturally a beautiful part of the 
body, becomes an unelastic, unpleasant looking part of 
the integument, having a thickened and brownish red, 
dirty appearance, losing all the elevations and depressions 
by which it is normally distinguished, and is also covered 
by crusts, and scabs, and fissures, in which bleeding is very 
readily excited. When the external auditory canal partici- 
pates in the morbid process, its caliber may be lessened or 
occluded, and thus deafness may be produced. 

Acute eczema, in its incipient stages, at least, may be 
confounded with erysipelas. A congestive seborrhcea of 
the outer ear may be sometimes considered as a chronic, 
scaly eczema. In seborrhcea, however, the swelling and 
infiltration is absent, and there is no moistness in the part. 
There is also a fatty feel to the structure, and a slight 
amount of itching. 

Prognosis. — In speaking of the prognosis, I should, first 
of all, call your attention to the fact, that relapses are very 
common in acute eczema of the ear; and that in the 
chronic form, it generally requires great patience and long 



TREATMENT. 55 

continued treatment before a favorable termination is 
reached. 

Treatment. — In the treatment, we should not keep the 
head or ear too much wrapped up. We should confine 
ourselves to keeping away the external air. The best 
mode of accomplishing this is by sprinkling the parts with 
starch or rice meal. Warm fomentations with astringent 
solutions, especially a dilute one of acetate of lead, 
generally shorten the acute stage, and lessen the itching 
or burning sensations. The use of fats and oils is es- 
pecially adapted for the chronic and the impetiginous 
forms. In employing them, we should take care that 
all the crusts are kept for sufficient time in contact with 
the ointments. I generally cause the patient, after the 
ear has been smeared with the substance used, to wear at 
night a little covering for the ear, made of soft leather, 
or strong linen ; and in the morning the crusts and scabs 
thus softened may be washed off. Immediately after the 
part has thus been cleansed, astringent applications are made 
for a time, and the ear then strewn over with the powdered 
material before mentioned. If this be not done the hair of 
the patient will adhere to the excoriated moist surface. 

It seems to be a matter of indifference as to what kind 
kind of oil or salve is used. Their chief action consists in 
softening the dried secretion, in order that they maybe easily 
detached and removed. , The simple diachylon plaster, 
equal parts with olive oil, is particularly recommended, 
besides ointments of oxide of zinc, of white precipitate, or 
of iodureted sulphur. In the squamous eczema, which is 
particularly obstinate, the daily use of a preparation of 
tar upon the part, e. g., birch tar (oc. rusci s. betul^e)^ or a 
coating of collodion is particularly useful. It is very im- 
portant, at the same time, to treat the integument of the 
neighboring parts, particularly of the head, if this is at the 
same time affected with eczema or seborrhcea, because the 



56 THE AURICLE IN GOUT. 

affection of the auricle is very frequently maintained by 
such conditions of the neighboring parts. We should also 
learn if the patient is in the habit of using irritating po- 
mades, hair ointments, or the like. When the irruption 
is yery extensive, a cold shower bath applied to the parts 
daily, is very beneficial. We should then protect the ear 
from the entrance of cold water. 

The Auricle in Gout. — An attack of gout is sometimes 
announced by a slight inflammatory and painful redness 
on the upper part of the auricle, while in persons with an 
arthritic diathesis, depositions of urates are quite often 
found in the auricle. 

Garrod 1 has recently called attention to the frequent oc- 
casion of uric acid depositions in the auricle, in the case 
of individuals with the arthritic diathesis. According to 
him, these arthritic deposits were the most frequent of all 
the external symptoms of this sort, and they therefore are 
of some importance in the diagnosis of gout. Among 
seventeen patients with gout, in whom the deposits of 
urate of soda were found, Garrod found them on the ear 
nine times, and at the same time in the vicinity of the 
joints; seven times on the auricle alone; and of all the 
cases where they existed in the joints, there was only one in 
which they could not also be found in one of the ears. 
They were most frequently found on the upper portion of 
the border of the helix. They have not yet been observed 
on the lower third of the auricle. Their size varies from 
that of the head of a pin to that of a pea. They are said 
to be formed most frequently after an attack of gout, and 
generally without any local symptoms. 

Occasionally there is a slight pain or pricking sensation 
felt in them before the attack. Charcot* confirmed these 



1 The Nature and Treatment of Gout, London, 1859. 
2. Gazette med. de Paris, i860, p. 487. 



DEFORMITY OF THE AURICLE. 57 

observations before the Socii/e de Biologie, and enlarged upon 
them in some respects. 

I would here like to call attention to the fact, that not 
unfrequently in persons who did not appear to be affected at 
all with gout, and occasionally in those who were very young, 
I have observed spots in the auricle of varying size, circum- 
scribable, and partially movable in the cartilage, especially 
on the upper portion of the furrow of the helix. I can give 
no more exact idea as to their nature ; but they feel like 
partial calcareous or osseous degenerations. Leuckart and 
Heinrich Miiller 1 have shown that circumscribed spots of 
calcareous degeneration may occur in the reticulate cartilage 
of the ear, at least in animals. They might be confounded 
with the above described deposits of urate of soda, occuring 
in persons with the arthritic diathesis. 

Malformations. — Congenital malformation or deformity 
of the auricle is by no means unfrequent. Together with 
this external abnormal condition, there is generally found 
an imperfect or abnormal condition of the auditory canal, 
of the cavity of the tympanum, or even of the labyrinth. 
The auditory canal is not unfrequently completely closed, 
or even absent. The operative opening of the canal thus 
naturally closed, would usually be of slight benefit, on 
account of the affection of deeper parts, not to speak of the 
very great difficulty of keeping open a canal thus newly 
formed. Such malformations appear to occur more fre- 
quently on one side alone. 2 According to Virchow, 1 con- 
genital anomalies of the external ear are most frequently 
to be referred to imperfect closure of the first branchial 
.fissure, and commonly occur in connection with cervical 
branchial fistula and cleft palate. 

i Wiirzburger Naturwissenschaftliche Zeitschrift, I Heft, 1 Band., S. 92, et seq. 

2 Welcker. Archiv. fur Ohrenheilkunde, 1, S. 163. 

3 Virchow's Archiv., Band. XXX and XXXII, S. 518. 

8 



LECTURE V. 

THE EXAMINATION OF THE EXTERNAL AUDITORY CANAL AND 

MEMBRANA TYMPANI. 

Importance of the examination of the external ear in the diag- 
nosis of aural disease ', and for science in general ; the aural 
speculum ; the illumination with the concave mirror, as com- 
pared with the methods formerly employed ; historical ; the 
angular forceps. 

Gentlemen : Before we pass on to the diseases of the 
more deeply situated parts of the ear, we must look at the 
means employed in diagnosticating them. We have, then, 
to consider the methods for the examination of the external 
auditory canal and the membrana tympani. 

It is not possible to form a positive diagnosis in dis- 
eases of the ear, without being able to thoroughly examine 
the auditory canal and membrana tympani. 

If it be true in general, that the objective inspection of 
any organ forms the most important part of an intelligent 
examination of a patient, it is especially so in the diagnosis 
of aural affections. There are no cases where we can draw 
so little evidence from the history of the patient and the 
subjective symptoms, as in those occurring in aural practice. 
A furuncle, or an eczema of the external auditory canal, may 
cause intense pain and profound deafness; a simple plug of 
wax may excite the most troublesome vertigo, and unbear- 
able tinnitus aurium, while, on the other hand, we may often 
meet with large perforations of the membrana tympani, 



IMPORTANCE OF AURAL EXAMINATION. 59 

and very great changes in the cavity of the tympanum, 
without complaint from the patient of anything more than 
of some impairment of hearing. 

The membrana tympani forms the partition wall between 
the auditory canal and cavity of the tympanum, or middle 
ear ; and the inner side of it contains a coating of the 
mucous membrane of the middle ear, and thus takes part 
in all the diseases of the cavity. The color and reflection 
of this membrane, its inclination to the auditory canal, 
and its curvature are considerably influenced by the 
condition of the parts behind it, especially by that of 
the cavity of the tympanum, and of the Eustachian 
tube. The appearance of the membrana tympani differs 
therefore, according as the cavity of the tympanum and 
its mucous membrane is in a normal or abnormal con- 
dition ; according as the Eustachian tube is permeable or 
closed. 

The examination of the auditory canal, and especially 
of the membrana tympani, is therefore the most impor- 
tant means of diagnosis, and is consequently first under- 
taken in our objective examination of a patient. If I now 
say to you, that in accordance with my experience, the 
greater number of surgeons are not in a position to appre- 
ciate what is to be seen in the outer ear, much less to 
critically examine it, you will fully understand the peculi- 
arity of the ethical and scientific condition in which the 
practice of aural surgery was at one time, and in which it 
still to some extent continues. 

It is an undeniable fact, that the greater number of 
practitioners cannot examine the ear at all, and a secret is 
scarcely made of such ignorance. This fact is of vast 
importance. All the evils from which the aural surgery 
of the present day suffers, may be traced back to this. 
Whoever does not know how to examine the ear, should 
not attempt a diagnosis of its affections. If he does not 



60 NEGLECT OF STUDY OF AURAL DISEASE. 

know what is the matter with the patient, he has no con- 
ception of what is to be done for the disease. Each at- 
tempt at treatment, without an examination, must remain a 
very vague one, and, as a rule, have no result, unless some 
happy accident accomplishes something for the patient. 

The slight estimation in which aural surgery is, held by so 
many of the physicians, as well as by the laity, also depends 
to some extent on these circumstances. It is an old psycho- 
logical, and very easily understood fact, that we practise 
willingly, and highly esteem what we understand, and feel 
ourselves certain in ; and on the other hand, what we imper- 
fectly understand, and we do not like, we, if possible, 
push aside and neglect. 

Some pains-taking physicians have confessed, that it 
annoys them very much when a patient with disease of the 
ear comes to them, for they cannot examine him properly, 
and they are ashamed to attempt to do anything for a 
patient without knowing what his disease is. Almost 
every physician is glad when he has got rid of an ear 
patient in any way. 

The reason that physicians in general so little esteem the 
treatment of diseases of the ear, and assert this so openly 
at each opportunity, is because they think in this manner 
to be able to soften and conceal, before the world and 
themselves, the sense of their own want of knowledge. 
Very naturally, the very poor prospect for aid from phy- 
sicians, was long since known to the laity. Never do 
patients seek a physician so late as in aural diseases, and 
never do they so commonly consult advertised books and 
try quack remedies. Patients feel themselves without help 
from the side where in other cases they find it; therefore, 
quackery has a fair field. 

Since, then, the profession have so little of an independ- 
ent judgment on the subject of aural disease, windy and 
superficial cabblings have been palmed off as the results of 



EXAMINATION OF THE AUDITORY CANAL. 6 1 

scientific labor, even up to the latest period, and medical 
phantasies and nonsense, have been permitted to be woven 
into the whole subject. 

You see, gentlemen, that we always come in a dreary- 
circle again to our starting point, viz., the fact that the 
vast proportion of the profession, up to the present time, 
have not understood how to examine the ear. In this 
fact we shall find the most satisfactory reason that the 
knowledge of aural diseases stands to-day, much less de- 
veloped than other departments of medicine, and that their 
scientific investigation was so lately undertaken. 

What, then, is the ground of this improper position ? Is 
the examination of the auditory canal and membrana tym- 
pani so particularly difficult, or were the previous methods 
not good, and capable of being generally practised ■? Un- 
doubtedly it is not in the difficulty, but in the method. 
That the previous modes of examination are not good and 
practical in the full sense of the word, is sufficiently proved, 
from the fact that even now so few physicians can examine 
the ear. A really good method would have long since 
broken the way, and things for years past, would have 
stood in a different position from that in which they 
unfortunately now do. The fact, that a great number of 
easily distinguished and very common changes and abnor- 
mal appearances in this membrane, concerning which we 
shall speak more fully, have been entirely unperceived by 
aurists, speaks still more for the defects of the previous 
methods. 

Let us now turn directly to the subject. Without 
any assisting means, we can see only the opening of the 
auditory canal. If we press the tragus a little forward, 
while* at the same time we draw the auricle backward, 
we widen the entrance, and we are able to examine the 
first part of the passage. We are not able, in this man- 
ner, to look any deeper unless the canal is abnormally 



62 EXAMINATION WITH THE AURAL SPECULUM. 

wide, which is sometimes the case. Generally, the audi- 
tory canal is too narrow to allow sufficient light to fall 
upon the deeper part, and upon the membrana tympani ; 
the canal does not run in a straight line, but it has an an- 
gular curvature in its course, and there are also little hairs 
which grow from the side of the osseous part, encroaching 
upon the caliber. If we wish to see the membrana tym- 
pani, which is the deepest lying part, perfectly and exactly, 
we must remove all these hindrances ; in a word, we must 
sufficiently illuminate the back ground, change the crooked 
course of the canal to a straight one, and finally, push the 
little hairs to one side. 

All these requirements we may attain in the simplest 
and best way, if we place a small tube in the passage, an 
aural speculum, and throw the day light through it upon 
the parts, by means of a concave mirror. These tubular 
specula, which have no opening at the side, are to be pre- 
ferred to Itard's or Kramer's ear specula, still much used 
in Germany. These latter are much larger and clumsier, 
not so convenient or easily adapted to their purpose. 
Generally speaking, all the widening of the bony canal that 
is necessary, may be accomplished by the coniform spe- 
cula, and we have no need for a dilator. Such an instru- 
ment, if pressed open while in the ear, often causes pain. 
The value of this valvular speculum is also often somewhat 
lessened, because the little hairs and the epidermis are apt 
to protrude through the sides, and obstruct the view. 
We are obliged to hold the valvular and handled specu- 
lum as long as the examination lasts, while specula of the 
other kind, of the proper size, and properly placed, generally 
remain in position, while the hand is free for other manipu- 
lation. 

Kramer's ear speculum has therefore no advantages over 
the much smaller and handier tubular speculum ; but, on 
the contrary, the disadvantages attached to its use are 




EXAMINATION WITH THE AURAL SPECULUM. 63 

considerable. The ear specula which I use are silver, cylin- 
drical tubes, having a funnel shaped outer surface. We 
may generally employ three, each of different caliber, to 
be used according to the width of the canal undergoing 
examination. These tubes are placed in each other, and 
may be conveniently carried in any vest pocket. 

The cut represents the exact size of the FlG - 5- 

instruments. They should be thin, the 
metal evenly worked, and the smaller open- 
ing rounded off, in order not to injure 
the auditory canal by their introduction. 
It is of scarcely any importance, when the 
method of illumination by means of the 
concave mirror is practised, whether the 
interior of the speculum is polished or is 
black. 

(I use the aural speculum, introduced by Sir Wm. Wilde, 
but first employed by Gruber, the elder, of Vienna. It is 
a simple conical tube. St. J. R.) 

When we wish to use these specula we draw the auricle 
somewhat backward and upward, and thus overcome the 
curvature of the auditory passage. We then introduce 
the speculum with a slight rotary motion of the other hand, 
without using any force whatever. If the instrument be 
now introduced, the second hand becomes superfluous, and 
the thumb of the same hand which holds the upper portion 
of the auricle by the index and middle finger, presses 
upon the lower border of the outer opening of the specu- 
lum. In this way, the tube and canal are kept in the same ■ 
direction, and may both be changed to different directions, 
in order to bring the membrana tympani and the different 
parts of the auditory canal, on all sides, into the field of 
vision. Beginners are apt to leave the ear to itself, and 
hold the speculum alone. In this manner, we may easily 
press against the auditory canal, occasion pain, and pre- 



64 ILLUMINATION OF MEMBRANA TYMPANI. 

vent the full mobility of the speculum. If we draw the 
speculum slowly out, after we have made the examination 
of the drum, we can see each individual part of the canal 
exactly. 

Of greater importance is the question, how can we best 
illuminate the auditory canal and membrana tympani ? 
The valvular speculum is less convenient than the tubular 
one, which I have described, yet we can examine the ear 
well and thoroughly with it, even if it be a little trouble- 
some. It is not so, however, with the former methods of 
illuminating the ear. They have proved themselves to be 
wholly insufficient. 

Until recently, we have been in the habit of using only 
sun-light or bright day-light, falling through a window 
into the auditory canal. This method is very deficient in 
many respects. We can only employ it under certain cir- 
cumstances ; we cannot see with sufficient distinctness 
with it. It is also very inconvenient. 

We may learn from our daily experience with sun-light 
illumination, that it is a great deal too glaring and blinding, 
to serve as a means of direct illumination where small and 
indistinct changes of form and color exist. It is an optical 
fact that direct sun-light, in general, is not so good for use 
as interrupted and diffused light. Certainly, in every day 
life we never expose an object, from which we wish to bring 
out delicate tints of color or minute elevations on the sur- 
face, to the direct sun-light ; such objects, for instance, as 
a picture, or a piece of ivory carving. 

We could examine the ear better with simple direct day- 
light, than with sun-light, if there were not a number of 
objections connected with its employment, and if a number 
of favorable circumstances, working with us to secure the 
desired end, were not required. If we wish to make use 
of day-light, in examining a patient, he should be brought 
to the window. Bedridden patients in most cases object 



ILLUMINATION OF MEMBRANA TYMPANI. 65 

to such a removal. The window must be free from cur- 
tains, blinds, etc. If it do not look on the open sky, or 
be not opposite a house on which the sun shines, the light 
will not be sufficient to illuminate the deeply lying parts of 
the ear. The position of the surgeon is also a very bad 
one in this method of examination. He must stand be- 
tween the light and the patient, and thus he easily makes 
a shadow with his head. This will more commonly occur 
when the surgeon is not far sighted. Indeed, if the surgeon 
has had but little practice in examining the ear, the formation 
of a shadow with the head is very troublesome, precluding, 
as it does, the possibility of seeing the drum of the ear. 

For the foregoing reasons, the head of the surgeon cannot 
be very near the ear. Hence, minute changes, especially 
in the membrana tympani, may pass unnoticed even to the 
sharp sighted ; thus the method must always be limited to 
making out coarse distinctions. In order to be able to 
see small objects, the distance of the eye from them cannot 
exceed a certain amount, or retinal images occur which are 
too small to form an isolated impression. More than all, 
we cannot always have bright day-light at our service. In 
a climate so rich in clouds and rain as that of Germany 
and England, we must often wait weeks to find day-light 
enough to make an examination of the ear. This last fact 
demands the introduction of another method, or one that 
does not depend upon weather. For how can we speak of 
a progressive, exact, estimation and examination of a single 
case, if we cannot daily, and at any hour in the day, have 
at hand and employ the means of such an examination ? 

This great deficiency — the dependence of the illumina- 
tion and examination upon the weather, and the kindness of 
the skies — was naturally felt long ago; and it was attempted 
to help the matter by means of an apparatus which would 
always furnish a source of light. The first attempts, ex- 
cept the proposition of Fabricius ab Aquapendente (1600), 

9 



66 ILLUMINATION OF MEMBRANA TYMPANI. 

to place a light behind a flask of water, and throw the 
concentrated rays into the ear, were made in the middle of 
the last century by an English army surgeon, Archibald 
Cleland. The surgeon held in his hand a convex lens of 
three inches focal distance, and the center of which was 
opposite a wax light, so placed that the united rays of light 
were thrown through the lens into the auditory canal. 

All the different sorts of illuminating apparatus which 
have been produced since this, are no very great im- 
provement on Cleland's, which was a very great advance on 
previous methods. Instead of the convex lens, a concave 
one is used ; instead of wax light, gas, oil, etc. Some of 
them are enclosed in a case, have a tube attached, etc. 
Some of these contrivances are very clumsy and com- 
plicated. Many of them which have been suggested, even 
very recently, are perhaps considered of more value by their 
inventors than by the profession in general. All of them 
have attained some celebrity, and a few, consisting essen- 
tially of an artificial source of light and a concave mirror, 
are still constantly used by some aural surgeons. 

To all of these methods there is the objection, that we ob- 
tain artificial, colored light, which adds something foreign to 
the natural color of the parts, so that the actual properties 
and color are not quite correctly estimated. Some of 
these appliances dazzle the examiner by the power and 
nearness of the light, which stands exactly opposite the eye 
of the surgeon. In the use of some of them, there is 
also danger of setting the hair on fire, especially if it does 
not lie very smoothly on the head. These means of exa- 
mination have never acquired any reputation among general 
practitioners, and are scarcely to be found, except in the 
consulting rooms of specialists. 

But it is not necessary to have any artificial light, or 
complicated contrivances, in order to always obtain an 
illumination of the canal and membrane, which is more 



Fig. 6. 




J..* /-.._> 



68 



ILLUMINATION OF MEMBRANA TYMPANI. 



than sufficient. If we take a sufficiently large and powerful 
concave mirror, and by means of it throw a powerful stream 
of ordinary day-light upon the ear, we can see the parts 
clearly in the minutest detail, as is only possible with the 
naked eye. This method sweeps away all the evils attend- 
ing the other ones, of which we have just been speaking. 
The mirror should be of 5-6 inches focal distance, and 
not less than 2I to 3 inches in diameter. Metal mirrors 
are not so good as glass, and they are most convenient if 
perforated in the center, or if the quicksilver covering 
is removed at this point. The mirror of the ophthalmo- 
scope is not adapted for this purpose, being too small, 
and having too great a focal distance. Hence its illumina- 
ting power, if we do not use a lamp, but simply diffuse 
daylight, is too weak. 

Coarse distinctions, such as whether the membrana tym- 
pani is wholly or partially covered, grey or red in color, 
whether the canal be stopped or free, we can generally as- 
certain very well with the small mirror. In certain cases, 
e. g., during operations, or in watching the membrana 
tympani during an air bath, I fasten the mirror to the 
forehead by means of a forehead band, having a ball and 
socket joint, as in the use of the laryngoscope. 

The use of the reflector enables us to turn the ear away 

from the window, 
the patient being 
between the window 
and the surgeon. 
We can examine 
adults most easily 
in the standing po- 
sition ; in the case 

of children the sur- 
lranslator s forehead band. 

geon may sit down, 

while the little patient stands on a stool. 



Fig. 7. 




ILLUMINATION OF MEMBRANA TYMPANI. 69 

Experience teaches us, that this method of examination 
answers all requirements, and that its advantages in oppo- 
sition to those formerly practised are very great. The 
colorings of the part are not changed, as occurs in the use 
of artificial light; but they are distinctly and truly reflected. 
The concave mirror is a simple appliance. It is not costly, 
and is portable. The greatest advantage of this method 
of illumination, however, is that it may be practised in all 
kinds of weather. It may also be used in case the patient 
lies in bed, a candle or lamp being employed if necessary; 
and we are not even obliged to turn the patient to a win- 
dow if a light colored wall be near. 

Furthermore, the examination of the ear in this manner 
is easy and convenient. There is no danger of making a 
shadow with the head, and we can get very near to the 
patient, and see clearly the smallest and finest distinctions 
in form and color, which even the sharpest eye could not dis- 
tinguish when removed at any distance. It is by no means 
difficult to learn this method of examination ; and since it 
has become known it has become very widely adopted. 

(It is convenient to have a revolving chair in the con- 
sulting room, so that the patient is not obliged to rise, 
when the examiner turns from one ear to the other. The 
author's method of illuminating the auditory canal and 
membrana tympani, was introduced by myself into the New 
York Eye and Ear Infirmary in 1863. It soon superseded 
all other methods of examination in that institution, was 
afterwards introduced by my friend, Dr. H. L. Shaw of 
Boston, into the practice of the infirmary of that city, and, 
if one may judge from the large number sold by the instru- 
ment makers of this city, has gone into very general use. 
My experience confirms all that Professor Troltsch claims 
for it ; and it is believed that we have nothing more to 
desire in the way of a method of examining the external 
parts of the ear. St. J. R.) 



7° 



ILLUMINATION OF MEMBRANA TYMPANI. 



The first forceps shaped " speculum auris" is pictured in the works 
of Fabricius Hildanus (Fabry, from Hilden, a place near Diisseldorf), 
in 1646. These dilating ear specula have not been much changed 
or improved since then. There are also many sub varieties of the 
tubular ear specula, of which one is about as useful as the other, and 
which are all better than the dilators. The one described by the 
elder Gruber of Vienna, more than 30 years ago, has served as a 




Method of examining the ear. 



HISTORICAL. 71 

model for all the subsequent ones. Its outer opening is only 10 mm. 
wide. The one suggested by Arlt is similarly made, but the diameter 
is oval instead of round. Both were made of German silver, and of 
thick metal. The specula suggested by Wilde in 1844, an d until 
lately always used by myself, are very good. They are conical silver 
tubes, with an outer opening of 15 mm. in diameter. The form 
described by Toynbee in 1850, consists of an oval cylinder, with an 
outer funnel shaped opening. The one here given (see fig. 5), bor- 
rows the round opening from Wilde's instrument, and the funnel 
shape from Toynbee's. 

Politzer suggested that the specula be made of hard rubber ; being 
black, these absorb a great deal of light. On this account, those 
having little experience in examining the ear, have more difficulty in 
seeing with them in cloudy weather, than with those which, like 
mine, are made of silver. On the other hand, when there is a good 
light, the color of the membrana tympani, which appears surrounded 
by a black ring, is twice as distinct. The india rubber specula are 
also much cheaper than those which are made of silver. 

The above described method of illumination with the concave mir- 
ror I claim as my own, not having heard anything of it from another ; 
and I showed it in December, 1855, at the Union of German physi- 
cians, in Paris. It was only till some time later, that I learned that a 
similar method had been proposed before, by a physician from West- 
phalia, Dr. Hoffman, of Burgsteinfuhrt, in 1841, who recommended 
the use of a centrally perforated mirror, with which to throw sun- 
light, or that of a bright day, into the ear, and thus illuminate the parts. 
This suggestion of Hoffman's does not seem, however, to have made 
any deep or lasting impression, nor to have been adopted by any of 
the well known aurists. It received so little attention that the books 
on diseases of the ear make no mention of it, with the single exception 
of that of Mr. Frank in 1845, and of Rau in 1856. The former, 
however, declares its illumination to be insufficient, 

It is advisable for the beginner in aural examinations, to 
illuminate the ear with the mirror alone, before the intro- 
duction of the speculum. If the two sides of the canal 
be pressed apart by the fingers, a part of the membrana 
tympani will be seen to be strongly illuminated ; and 
thus it is known in exactly what direction to look for it. 



72 ILLUMINATION OF MEMBRANA TYMPANI. 

Besides, in this way we glance over the walls of the canal, 
and we may judge as to its superficial condition, and the 
course or direction of the canal, especially as to the amount 
of inclination downwards of the wall of the cartilaginous 
portion, and of the more or less straight course of the upper 
wall. The speculum should, therefore, be placed close to 
the upper wall, in order to introduce it as far as possible, 
without causing pain, and to bring it in the proper position 
with relation to the plane of the membrana tympani. 

Since the ear lies in the middle of the head, it is well to 
turn the head somewhat to one side, in order that as small 
a portion of the mirror as is possible is put in the shadow 
by it. The examiner will soon learn how to give such a 
direction to the head of the patient, and the mirror, as 
will make the examination most convenient, the illumina- 
tion as good as possible, and enable the surgeon to avail 
himself of the best portion of the horizon as a source of 
light. By turning the mirror lightly to one side and the 
other, we soon find the point where the deeper lying por- 
tions are best illuminated. White or light gray clouds 
afford the best light for examining the ear, as is the case 
in making microscopic examinations. Sun-light thrown 
directly into the ear is too dazzling, and it causes at the 
same time a distinct feeling of heat in the membrana tym- 
pani. If we find the sun-light immediately opposite us, 
we turn the mirror a little to one side and use the surface 
of the adjacent illuminated wall, as the source of light. 

In a person with a wide auditory canal, in which the 
speculum can be introduced far enough, it will generally 
remain fixed, without any farther assistance, so that the 
hand is free ; but in the case of many persons, especially 
the young, it is necessary to draw up the auricle and hold 
in the speculum during the whole time of the examination, 
or it will come out, or lose its position. The larger the 
speculum which is used, the easier it is to get a view of 



ILLUMINATION OF MEMBRANA TYMPANI. 73 

the whole membrana tympani, and the more readily will it 
retain its place. 

When the membrana tympani is seen, we look first 
for the yellow line, running from above downward, the 
handle of the malleus ; and taking this as a guide, we then 
look at the other parts of the membrane. We then ob- 
serve the color of the membrane, whether it be natural, 
regular, or different in different parts ; whether the drum 
is translucent, or morbidly thick and opaque ; whether the 
brilliancy of the surface be normal ; if the cone of light, or 
light spot, is present and in an unchanged shape. Fur- 
thermore, we should observe whether the membrana tym- 
pani is abnormally flat, or oblique in position, or too con- 
cave. The observation of the position of the handle of the 
malleus, which is not unfrequently seen to be shortened in 
perspective, as well as the impression as to the size of the 
membrana tympani, will generally lead to correct conclu- 
sions as to these latter points. 

According to Politzer, the mnmbrana tympani appears the larger, 
the less its angle of inclination ; and I have long since frequently 
observed, that after the employment of the air bath, the drum seemed 
considerably larger. According to the same authority, the membrane, 
on account of the oblique position of its plane to our visual axis, 
always appears smaller and less curved inwards on examination with 
the mirror than it really is, and when seen in anatomical preparations. 

We should compare the size of the two halves of the 
drum, and see whether the posterior and really larger half 
does not appear very small. We should also observe if 
there are not individual spots where there are variations in 
the curvature; if there is any vascular injection, especially 
on the handle of the malleus ; in which latter case, the 
short process of the malleus appears at the upper pole of 
the membrana tympani exactly like a white pustule; sur- 
rounded by a red ring. 
10 



74 



ILLUMINATION OF MEMBRANA TYMPANI. 



In withdrawing the speculum, we should examine the 
integument of the canal, and decide as to the amount and 
appearance of the cerumen present. 

In the examination of the ear, another instrument is 
frequently necessary, in order to remove flakes of epi- 
dermis, clumps of ear wax, hairs, and other little hindrances 
to a perfect view of the parts. We may use for this pur- 
pose either a button headed probe, or an angular forceps ; 
such as is seen in the engraving. The walls of the ca- 
nal are very sensitive, and we should be careful to avoid 
any vigorous contact by means of an instrument. We 
should call the attention of the patient to what we are about 
to do, in order that he may avoid all movement of the 
head while the forceps are in the ear. Of course, all such 
proceedings should only be taken when there is a good 
illumination of the parts. Any fluid secretion may be re- 
moved by a camel's hair brush, placed in the forceps (or 
by a dentist's cotton holder) ; and in the same way, a 
solution may be applied to any part of the ear. 

Fig. 9. 




Angular forceps 



LECTURE VI. 

THE SECRETIONS OF THE AUDITORY CANAL, AND THEIR 

ANOMALIES. 

Diminished secretion of cerumen ; the importance traditionally 
ascribed to it ; plugs of cerumen; their gradual accumulation 
and sudden manifestation ; their structure and causes ; ver- 
tigo and other symptoms ; prognosis and treatment. 

Gentlemen : In describing the diseases of the external 
auditory canal, we have to speak, first, of its secretions and 
their anomalies. In the same way that the fluid which 
lubricates the eye, is by no means a mere secretion of the 
lachrymal gland, but is also a product of the mucous mem- 
brane and Meibomian glands, so is it with the secretion 
of the' auditory canal, which we call "ear wax." This 
substance is furnished not only by the proper ceruminous 
glands of the ear, which are very similar to the sudoriparous 
glands of the remainder of the skin in their sinuous struc- 
ture, but also by all the other parts of the skin of the 
canal that have secreting properties. The very numerous 
sebaceous glands take part in the process ; and little hairs, 
also mixed with the ear wax, with dead scales of epidermis, 
which have been thrown off. 

Since the outer portion of the covering of the external 
auditory canal is a continuation of the common integument 
of the body, which has retained all its coarse and fine ana- 
tomical peculiarities, it can be easily understood, that the 
secretions of the auditory canal are commonly to be re- 
garded as identical with those of the integument. 



76 DIMINISHED SECRETION OF CERUMEN. 

This connection or identity of the skin of the auditory 
canal, with that of the surface of the body, has been but 
little regarded, scarcely even noticed ; consequently, too 
great an importance has been attached to its secretion, 
especially as to its quantity. Let us, therefore, turn our 
attention to the subject of diminished secretion of cerumen 
as well as to its increased collection. 

As regards the diminution of the secretion of cerumen, 
we may remark that we are apt to find a dry auditory 
canal, with little cerumen, in persons whose integument is, 
on the whole, very harsh and dry, containing little fat. 
This state of things may exist without the least affec- 
tion of the hearing. A Scotch physician, 'Thomas Buchanan, 
wrote several books, in the first part of this century, in 
which he called particular attention to the great signifi- 
cance of the cerumen. According to him, a large class of 
cases of impairment of hearing resulted from the diminu- 
tion in its secretion ; and thus the ear wax played a very 
important part in the human economy, entirely independent 
of the secretions of the general integument. These obser- 
vations found scarcely any attention or acceptance in their 
time, although the dryness of the auditory canal is con- 
sidered as a very important circumstance, both with the 
laity and the profession, with reference to acuteness of 
hearing. As remedies for this dryness, pencillings, and 
droppings of oils and balsams are practised. Among those 
applications glycerine has lately come into great repute. 
You will seldom see an ear patient, who has not, either 
through his own or a physician's recommendation, tried 
some such remedy. We find, also, in all the books on 
diseases of the ear up to the latest time, that the absence of 
ceruminous secretion is mentioned not as of itself a cause 
for impairment of hearing, but as a symptom of a deeper 
affection of the auditory apparatus. The abnormal dryness 
of the auditory canal, is considered by some of the latest 



DIMINISHED SECRETION OF CERUMEN. JJ 

aurists to have great importance in the causation of catarrh 
of the cavity of the tympanum, and nervous deafness. 
A priori, we cannot deny that there is such a sympathy of 
the external auditory canal, and its secretions, with the more 
deeply situated parts of the ear, or that there is a certain 
physiological unity of the various parts ; certainly they 
stand in dependence, the one upon the other. We can 
trace such a sympathy back to an anatomical basis, since 
the otic ganglion sends branches to the mucous membrane 
of the cavity of the tympanum, as also to the integument 
of the auditory canal. 

But what does experience and cool, unbiased observa- 
tion teach us here ? These alone can furnish definite 
conclusions in such inquiries as the present. You must 
remember that very many ear patients very willingly ascribe 
the origin of their trouble to the accumulation of ear wax, 
and hence are apt to introduce ear spoons and similar instru- 
ments for its removal ; and in accordance with their own 
or a physician's recommendation, to syringe the ear in 
order to accomplish the same result. In this way, an 
artificial dryness, a temporary absence of ear wax may be 
produced. You should always inform yourself by ques- 
tioning the patient, of the possibility of such a cause 
producing the dryness of the ear. Apart from such cases, it 
is certainly true, that in many acute affections of the middle 
ear, accompanied by rapid increase in the amount of blood, 
and of the secretions, for example in acute catarrh of the 
middle ear, there is very often a serous exudation on the 
surface of the auditory canal, with a profuse throwing ofF 
of epidermis. In the similar, but chronic affections of 
the middle ear, however, no such reflex action upon the 
secretions of the auditory canal is observed. It is further- 
more true, that in certain morbid drying and indurating 
processes, which we shall later on in the course of these 
lectures, recognize as sclerosis of the mucous membrane of 



J$ DIMINISHED SECRETION OF CERUMEN. 

the cavity of the tympanum, we often, if not always, find 
a particularly dry and wide auditory canal. 

This may be explained, however, by the fact, that per- 
sons having very little fat, with a very harsh dry skin, 
tensely stretched as it were over the bony frame, are more 
particularly inclined to such affections of the middle ear ; 
and in persons with the same sort of integument who havre 
good hearing, we generally find the same conditions in the 
auditory passage. 

As to the deficiency of cerumen in nervous deafness, we 
shall subsequently see, on what a weak footing such a 
diagnosis rests. 

Many surgeons assert that in acute diseases also, for 
example, in acute catarrh of the middle ear, there is also 
deficiency in secretion. It is difficult to see how such a 
conclusion can be reached ; for if the secretion occurred 
normally, before the attack, it is hardly possible for it 
suddenly to disappear so that we would be able to esti- 
mate the present capability of secretion, from the abun- 
dance or spareness of the cerumen. 

I hold to the belief, that the very prevalent idea, that 
many of the internal affections of the ear (we are of course 
not speaking of purulent affection) are regularly and pro- 
portionately connected with the diminution of secretion of 
cerumen, is chiefly traditional, and not confirmed by im- 
partial observation. I can only consider the absence, 
diminution, or increase of the product, as dependent upon 
the secretory power of the integument of the body ; but 
in this view, I do not include certain deeply seated acute 
inflammatory affections, affecting the whole ear, or those 
conditions of irritation which begin in the auditory ca- 
nal. People who have an oily skin, in whom the sudor- 
iferous or sweat glands, especially of the face, are easily 
excited to action, have, as a rule, more cerumen in the ear 
than those whose skins are dryer and harsher, no matter 



, 



AMOUNT OF CERUMEN. 79 

whether they have chronic catarrh of the middle ear or 
not. 

In most cases only the very moderate quantity of ear 
wax is secreted which covers the cartilaginous meatus as 
a thin layer. The superficial portion gradually becomes 
dry, and is lost, through the motion communicated to the 
cartilage of the canal, by the articulation of the lower jaw, 
and also during the night, in lying on the ear. If there is 
a vigorous secretion in the canal, more than an ordinary 
amount being produced, or than can be removed with the 
occasional aid of an ear spoon, or if there are circumstances 
which prevent the removal of the normally secreted wax, 
as is sometimes the case, or if there be any narrowing of 
the caliber of the auditory canal, the secretion will gradu- 
ally collect, and in the course of time may completely close 
the passage. 

Increased secretion of cerumen is by many authors 
referred to an acute inflammation of the canal. Kramer 
speaks of an inflammation of the cutis, whereby the ceru- 
minous glands, lying under, are made to sympathize, as 
manifested by an increased secretion of ear wax. Rau de- 
clares the increased secretion to be the result of an ery- 
thematous inflammation of the auditory canal. That 
hyperemia of the canal, inflammation or congestive irri- 
tation of the integument, increase its secretion, is evident 
from the nature of things. Such acute irritations, however, 
must not necessarily be ascribed to the collection of ceru- 
men ; and I am of the opinion that the greater number of 
cases of closure of the canal by inspissated cerumen, must 
not be regarded as consequences of any kind of acute and 
specific disturbances of the nutritive process ; but only as a 
result of a state of increased secretion or diminished removal 
existing for years, or even tens of years, until finally so 
much cerumen has collected, that the auditory canal becomes 



80 INCREASED SECRETION OF CERUMEN. 

filled. All the symptoms which such patients commonly 
speak of — a great buzzing and itching in the ear, or a 
feeling as if the ear were stopped up — are to be regarded 
as mechanical effects of the increased ear wax, and not as 
proofs of the described morbid process spoken of by the 
above named authors. This is a much simpler, and more 
natural view, and corresponds exactly to the results of 
careful and unprejudiced observation. 

You have already satisfied yourselves in our examina- 
tions of the ear, which we have lately begun, how different 
is the amount of cerumen secreted by different persons. 
I called your attention to the fact, that the auditory canal 
of many of our fellow students has only a very little ceru- 
men, while in others we found such a mass, on the side of 
the canal, that it even prevented a full view of the mem- 
brana tympani. In these latter cases we can reckon on a 
gradual stopping up of the canal, if the collection of a 
secretion be not prevented ; but all these persons were 
shown to have healthy ears ; they heard perfectly well, and 
were not aware of any increase in the secretion. Interrup- 
tion of the function of hearing will not show itself till the 
stoppage of the canal be complete, and the mass is pressed 
in upon the drum. 

The structure of many of the plugs of cerumen is also 
evidence that their formation occurs slowly. They are 
often exceedingly hard, and in old people they are generally 
interspersed with hairs throughout their entire thickness, 
and as it were tufted with them. The various secretions 
of the auditory canal take part very differently in different 
cases, in the structure of these formations. They some- 
times chiefly consist of epidermis, arranged in lamellae, 
filling up the entire meatus, and which, in consequence 
of the slight admixture of true cerumen, is only of 
a pale yellow or brownish color. Again, they are amor- 
phous, of a dark brown color, composed principally of 



INSPISSATED CERUMEN. 8 I 

sebaceous material and discolored exudation from the sweat 
glands, having some admixture of epidermis here and there 
in the more recent and lighter colored peripheral layers. 
The surface of olden plugs is sometimes as brilliant as 
mother of pearl, from the cholestearie existing between 
the layers of the epidermis. In children, where the throw- 
ing off of epidermis occurs more rapidly, such collections 
of cerumen have more of a bright yellow color, and honey 
like consistency. Bits of cotton, grains of corn, raisins, 
etc., at times form the nucleus of these collections, which 
sometimes have added to them substances collected from 
the atmosphere, such as coal dust, for example. 

Habitual increase of the secretion of the auditory canal, 
which may readily lead to its obstruction, occurs in chronic 
eczema. It also occurs in persons in whom the integument 
of the head produces much sebaceous material, or who 
perspire very much from the head. 

Among gardeners and carpenters, peasants, and rail road 
employes, and in general among those who are very much 
exposed to the sun in their arduous labors, I have found 
one and the same person the subject of inspissated ceru- 
men repeatedly during the year. The secretion is tempo- 
rarily increased by an often repeated congestion of the 
integument of the auditory canal, as well as after the 
repeated occurrence of furuncles. This latter form is a 
sort of congestive seborrhcea. 

(One of the causes of the occurrence of inspissated ceru- 
men may be said to be the habit which many persons 
have of pouring water into the auditory canal, for the 
purpose of cleaning it. This practice has a tendency to 
pack the cerumen into the meatus as it were, instead of 
removing it. I have observed several cases which seemed 
to me to be due to this habit. The only cleansing that 
the ears need, unless there be pus or the like, collecting on 
the walls of the meatus, is that which may be accomplished 
ii 



82 INSPISSATED CERUMEN. 

by a bit of fine cloth, wrapped about the little finger ; the 
natural and best instrument for manipulations in the audi- 
tory passage. St. J. R.) 

In other cases obstructing collections occur in the audi- 
tory canal, without there being any excess in the amount 
secreted. Thus we find these plugs of hardened cerumen 
very frequently in old persons. This may be due to the 
fact that the older a person is, the more readily such a 
slowly increasing collection can reach an amount sufficient 
to close the caliber of the canal ; and also because a collapse 
or falling inwards of the walls of the meatus, near its outer 
termination very often occurs in old persons, which, to- 
gether with the growth of the thick, bristle like hairs, may 
prevent the natural evacuation of the secretion. Perhaps 
in old age, the cerumen is also more tenacious, and ad- 
heres more firmly to the walls. 

Small quantities of cerumen may also, in some instances, 
excite annoying symptoms. These may occur if one of 
these little pieces form a wall across the caliber of the 
canal, even if it be a thin one, or if through any accident 
whatever, for example, if an attempt at its removal has 
not been continued long enough, and a bit of wax falls 
directly upon the membrana tympani, and thus causes 
pressure and irritation. But collections of cerumen do 
not generally cause any trouble until they have completely 
closed the auditory canal. Before this closure occurs, they 
are usually unnoticed. Thus we very frequently see pa- 
tients coming to us, on account of one ear alone, when 
the other contains hardly less wax, so* that only a little 
fissure remains unfilled. If now, through any external 
cause, the entrance of fluid during perspiration or bath- 
ing, the introduction of a pen-holder, hair pin, or the 
like, the plug becomes increased in volume, or assumes 
a position where it completely closes the canal, the patient 
suddenly experiences a condition of his ears, of which he 



INSPISSATED CERUMEN. 83 

before had no suspicion, and which he explains as he 
believes with perfect honesty, to be due solely to his 
interference. The medical profession also erred in the 
same way, and, founding their opinion upon the statement 
of the patients, considered that inspissated cerumen pro- 
ceeded from acute inflammatory processes, resulting in a 
sudden excessive amount of secretion. 

Symptoms. — Plugs of cerumen large enough to close the 
canal not unfrequently announce themselves in a very dis- 
turbing manner. The impairment of hearing is often so 
great, that it amounts almost to complete inability to hear 
ordinary conversation ; besides, such a foreign body as it is, 
increasing in size, constantly exerts pressure open, and 
sets up irritation in the walls of the canal and the outer 
surface of the membrana tympani. There is, also, an 
annoying itching sensation produced, or an unpleasant 
feeling of fullness and heaviness in the head, with extremely 
severe tinnitus aurium. Not unfrequently constant pain in 
the depth of the ear is felt, and even serious attacks of 
vertigo are experienced. 

(I once saw a young lady who suffered severely from 
inspissated cerumen, until it was ejected from the ear with 
an audible report, compared by herself to that of a pistol, 
when some relief was experienced. She came under my 
care for acute inflammation and perforation of the drum of 
the ear in question, caused by the pressure and irritation 
of this plug. I found in the other a large mass of im- 
pacted wax, probably similar to the one removed sua sponte 
from the inflamed ear, but which did not yet cause any 
unpleasant symptoms, and which I removed with the 
syringe. She recovered perfectly. St. J. R.) 

It is a very striking fact, and perhaps a new one to you, 
that these plugs of cerumen may produce attacks of ver- 
tigo. This symptom is quite frequently observed, and 



84 SYMPTOMS OF INSPISSATED CERUMEN. 

must be considered as a consequence of the pressure which 
the mass exerts upon the membrana tympani, whereby the 
whole chain of the ossicula auditus is pressed strongly in- 
wards, and hence upon the fluid of the labyrinth. — c Toynbee. 

There are people who only need to place the finger into 
the auditory canal, in order to press the whole column of 
air contained in it, against the drum of the ear, and thus 
excite dizziness, which may even go so far as to produce 
vomiting. Such attacks of vertigo we shall meet with in 
other varieties of affections of the ear, although they then, 
at least in part, depend on other causes. Nearly all of the 
profession have lost sight of the fact, that vertigo may 
be a consequence of disease of the ear. Many patients 
with impaired hearing having this symptom, have been 
considered as suffering from nervous disease or cerebral 
affection, and have been subjected to the most different 
and severe constitution treatment, from a course of baths 
at some watering place, to one of setons and moxas, while 
at the same time an examination of the ear would have 
been sufficient to reveal the true cause, when the case, in 
most instances, would have been treated with success. 

The following is an interesting case, which shows the 
relative importance of the history of a patient, and of an 
objective examination in the diagnosis : An old man came 
out of a drinking saloon, where he had taken an active part 
in the convivial proceedings, and on the way home struck 
against a wagon pole, awkwardly placed in the path. He 
was knocked down by it, striking his head upon the pave- 
ment. He thought that he lay there senseless about fifteen 
minutes. How far the fall, or the several glasses of wine 
were to blame for this, he could not say ; he admitted, 
however, to having been a little intoxicated. However, 
he got up and went home without difficulty. After a 
comfortable night, he found in the morning that he was 
almost perfectly deaf. The physician who was called in 



INSPISSATED CERUMEN CASES. 85 

shook his head, and immediately ascribed the deafness to 
the fall, and to striking the head on the pavement. He 
made a very serious matter of it to the family ; it was at 
least a concussion, or perhaps apoplexy of the cerebrum. 
The patient, who in other respects was well, was placed 
on light diet, cupped, and purged, and after a few days a 
seton was added to the remedies. The deafness remained 
the same, but the patient's bodily and mental system dete- 
riorated with the treatment. A month had elapsed when 
I was called in. After I had heard the history, I examined 
the ears, and found both canals perfectly stopped with 
cerumen. I caused this to be softened, and then to be 
removed by injecting warm water. In a few moments the 
patient heard perfectly well, and was cured, not only from 
his deafness, but also from cc a profound cloudiness of his 
intellect," which had occurred since the "concussion of 
the brain." In this case, the fall had displaced the already 
collected, but not yet observed, mass of cerumen, so that 
the canal was at once hermetically closed ; hence the sudden 
deafness. 

Remember this case, gentlemen, when patients come to 
you, who exhibit any kind of symptoms which may also 
possibly be referred to the ear, and imagine yourself in 
the position of this intellect-clouded, medicine-tormented, 
seton-bothered, and easily cured patient, and think of the 
situation of his otherwise skillful physician, when the 
nature of the cerebral disease was made clear to both. 
Still further, let us suppose that a few days after the applica- 
tion of the seton, the mass of wax, through any accident, had 
removed its position, or that the physician had thought of 
applying electricity, and accordingly had placed warm water 
in the ear, or that olive oil or any of the nostrums for curing 
deafness had been dropped into the ear, and some of the 
cerumen removed, what a new proof would have been fur- 
nished of the effect of the remedies in cerebral deafness even. 



86 STRUCTURE OF PLUGS OF CERUMEN. 

(At a time when I was one of the surgeons of the Eye 
and Ear Infirmary of this city, a man presented himself 
on account of a noise in the head, vertigo, etc. He re- 
ferred the beginning of his affection to an exposure to the 
rays of the sun about three months before ; although, on 
close questioning, it was found that he had no symptom 
of sun-stroke at that time, although he had suddenly suf- 
fered from dizziness and the noise in the head on a very hot 
day. He stated that he had been treated in a hospital for 
two months, for affection of the head, without benefit. The 
removal of a plug of inspissated cerumen effected a cure 
of all the head symptoms. St. J. R.) 

Many patients, affected with impaction of cerumen, in- 
form us that their condition varies in accordance with 
certain influences, and that these variations occur with a 
perceptible crackling sound, or the like. Many say that 
they become deaf as soon as they lie down, and thus press 
upon the ear ; and that the deafness disappears as quickly 
as they rise and shake the head, or pull the ear. Others 
become deaf every morning as soon as they wash the meatus, 
or clean it with a handkerchief. These are all circumstan- 
ces which go to prove to us, how the masses of cerumen 
are affected by change of position ; and that the hearing 
power is first markedly disturbed, when it completely closes 
the auditory canal. 

These plugs of inspissated cerumen are by no means of 
an entirely harmless nature, but exactly like tumors, which 
are constantly enlarging, they may become injurious to the 
parts adjacent by their size and consequent pressure. 
Toynbee shows in several instances how harmful may be the 
effects, which such collections excite on the surrounding 
parts. He observed in connection with a dilatation of the 
auditory canal in consequence of pressure, deficiencies in 
the anterior, upper and posterior wall of the passage, be- 
sides thickening of the membrana tympani, inflammation 



RESULTS OF INSPISSATED CERUMEN. 87 

and perforation. I myself made a post mortem examina- 
tion of a case, 1 where a plug of cerumen, wholly filling the 
canal, and evidently one that had existed for a long time, 
had produced a dilatation of the whole caliber of the osseous 
part of the canal, with atrophy of the periosteum, and a 
perforation of the membrana tympani; so that a portion of 
the impacted cerumen penetrated the cavity of the tym- 
panum. Since this, several such cases have been reported 
by other members of the profession. 

As evidence that long existing masses of cerumen, that 
are constantly increasing in size, may cause the partial 
destruction of the bony meatus, I may mention a case of 
which I happened to make a post mortem examination. 
On one side I found a very large plug of cerumen, with a 
symmetrical dilatation of the bony canal, and a large round 
aperture in the anterior wall, while the other canal was free 
from any collection, was of normal caliber, and in other re- 
spects in a natural condition. After the removal of a 
collection of this sort, we not unfrequently find the epider- 
mis of the membrana tympani thickened, in a state of cal- 
lous degeneration as it were. The membrana tympani 
often seems to be markedly pushed inward, as if it had 
been for some time pressed into the cavity of the tym- 
panum, and it then, of course, diminishes the space of this 
part. We should also mention, that collections of dried 
pus, which are not unfrequently dark colored from admix- 
ture of blood, may sometimes be mistaken for impacted 
cerumen. Fungous growths in the auditory canal, to which 
Wreden has lately called our attention, may also have been 
mistaken for collections of ear wax. 

We should be guarded in our prognosis, not immedi- 
ately giving a favorable one, when we meet with such a 
collection, since the complications and the consequences 
may be very different and numerous. The us£ of the 

1 Virchow's Archiv., B. XVII, Sect. II, S. 10. 



88 INSPISSATED CERUMEN TREATMENT. 

tuning fork furnishes assistance in the diagnosis. (I shall 
speak of the value of this instrument in the examination 
of the ear, in a subsequent lecture.) When the tone of a 
tuning fork, placed with its handle on the median line of 
the vertex of the head, is heard better in the normal ear 
than in the one which is stopped up, we may be certain 
that some complication exists, and that the patient will 
not improve much in hearing after the removal of the 

wax. 1 

• 

Treatment. — From the foregoing it is evident that the 
surgeon, in the removal of these masses, must work slowly 
and with care, for he cannot know in what condition the 
deeper parts may be. You will never, then, begin with the 
use of forceps, ear spoons, etc., by which the plug is easily 
pushed inwards, and great pain and other evil results are 
caused to the patient. The only proper method to be adopted 
is the use of injections of warm water, with which, how- 
ever, we must use no violence. If the mass proves to be 
very hard, or the patient troublesome, we can fill the ear 
with warm water, and allow it to remain some time upon 
the plug, thus softening it, repeating the operation as often 
as may be necessary ; and thus it may be easily loosened 
and swept out by the subsequent injections. Do not 
neglect to say to your patient, to whom you advise such 
a course of treatment, that the deafness will increase, lest 
on following your advice he becomes worse and fail to 
return. Oil and glycerine do not appear to loosen the 
masses so well as simple warm water, to which we may add 
an alkali, or soap. In syringing, we direct the stream as 
much as possible upon one or the other border of the col- 
lection, in order to more quickly loosen it from the wall 

i Toynbee, Diseases of the Ear, London, i860, p. 48. Of 160 ears, where he had removed 
such masses, ^Toynbee reports only sixty where the hearing power was completely restored ; in 
forty-three, considerably improved j in the remaining sixty-two, there was no, or a very little 
improvement. The result of my observations has been similar. 



INSPISSATED CERUMEN TREATMENT. 89 

of the canal, or from any hairs which may retain it, when 
the water will pass behind the plug and sweep it out as a 
whole, and we are able to remove it as it approaches the 
meatus, with a forceps. Sometimes we thus obtain a cor- 
rect cast of the canal, on which we can see the figure of 
the outer surface of the membrana tympani. 

We should not continue the syringing for too long a 
time at once; if the plug of cerumen be very difficult to 
remove. We should not be annoyed if we are sometimes 
obliged to give several sittings for the removal of a particu- 
larly obstinate plug, in the intervals of which the patient 
may use drops upon the cerumen, that may have the 
effect of softening it. After the cerumen is removed, the 
ear may be protected from the wind or cold for the next 
day by a bit of cotton, placed in the meatus. Cases have 
been observed, where a neglect of this precaution has been 
followed by severe inflammation of the ear. 1 Those who 
have the normal hearing power restored, should avoid very 
loud sounds ; for after this great change in the condition of 
the ear, even the sound of a powerful voice is unpleasantly 
loud. Immediately after the syringing, the membrana tym- 
pani and integument of the canal generally appear more or 
less injected. This redness, as a rule, disappears in a few 
hours. If the membrana tympani be pushed inward, in 
consequence of the pressure so long exerted upon it, a 
subsequent treatment with the catheter will be of advan- 
tage. (I have found quite a large proportion of cases 
where the use of the catheter, or of Politzer's method of 
inflating the middle ear, was indispensable in order to 
relieve the membrana tympani from the effect of the long 
continued pressure of a plug of wax upon it. It is gene- 
rally sufficient to thoroughly inflate the middle ear, once 
or twice, soon after the wax is removed. If any prolonged 

1 Schwartze, Prakt. Beitrage zur Ohrenheilkunde, S. 3. 
12 



90 INSPISSATED CERUMEN TREATMENT. 

treatment is required, the bulging in of the drum can 
hardly be caused by the pressure of cerumen. I have 
seen perfect relief follow the removal of hardened cerumen, 
in cases where it has remained in the canal for years. In 
one case, recorded in my private note book, a patient had 
suffered from partial deafness in both ears, and tinnitus 
aurium for five years ; which symptoms were all removed 
by syringing. In another, still more remarkable case, a 
patient who came to my clinic at the University Medical 
College, asserted that she had been affected for twenty 
years, and that the removal of the wax afforded perfect 
relief. St. J. R.) 

If there is any disposition to seborrhoea of the auditory 
passage, the part should be pencilled with an astringent, after 
having been previously syringed with luke warm water. 



LECTURE VII. 

SYRINGING THE EAR ; FURUNCLES IN THE AUDITORY CANAL. 

Gentlemen : A professor in an eminent medical faculty, 
to whom I announced my purpose to occupy myself espe- 
cially with the investigation and treatment of diseases of 
the ear, responded (of course, this was years ago) with a 
smile : " There is nothing more to do for ear cases than 
to syringe the ears, and put on a blister." Many learned 
and unlearned practitioners ascribe a similar high and 
universal value to syringing the ear. Perhaps, then, I 
may be excused if I devote a few words to this simple 
procedure. 

Simple as it is, we shall be able to satisfy ourselves that 
very often physicians themselves cannot properly syringe 
the ear, and that there are medical institutions where there 
is not even a proper apparatus for the purpose. Yet the 
matter is by no means an immaterial one. It is not only 
true that many patients are immediately cured by this sim- 
ple process, but there is also a class of cases, for instance, 
those patients suffering from otorrhoea, who, above all 
things, require a regular removal of the secretion, if we 
would keep the morbid process at a stand-still, or improve 
it. We shall, at a subsequent time, inquire into all the 
circumstances which require a systematic and constant 
syringing of the ear ; and we shall see that they are often 
cases which cause the most pain to the patient, and which 
not unfrequently lead to death. You see then, gentle- 
men, that much may depend on the possession of a good 
syringe, and its proper use. 



9 2 



SYRINGING THE EAR. 



I show you here the instrument which I 
use. It is of pewter or tin, has on one end 
a ring for withdrawing the piston, and on 
the other a blunt coniform nozzle of bone. 
The portion lying next to the ring, and 
which unscrews, is somewhat broader and 
more projecting, so as to afford a place for 
the two fingers to hold the syringe. The 
two rings at the side which many aurists 
employ seem to me superfluous. As we 
seldom need a long continued stream of 
water, or great power of the stream, smaller 
syringes are greatly to be preferred to larger. 
I recommend an instrument of this same 
form, but of half the size, to patients for 
their own use. I think horn and glass syr- 
inges the least practical. All sharp pointed 
instruments should be avoided, for the 
patient can easily do injury to the auditory 
canal with them, while the blunt point can 
be introduced without danger as far as it 
will go. If the instrument be too blunt 
and thick, the meatus is easily overfilled by 
it ; and thus the fluid cannot find its way 
out of the ear, and thus the pressure on 
the membrana tympani becomes too great. 

In using the syringe, we remember the 
curvature of the canal, and that when we 
do not draw the cartilage upwards and 
backwards, the upper wall only will be 
washed, while the deeper part and drum of 
the ear will be scarcely touched by the 
water. We take hold, then, of the cartilage 
of the ear with the left hand while we are 
using the syringe, as we have seen is neces- 
sary in the introduction of the speculum. *<**<* syringe 



SYRINGING THE EAR. 93 

If you would be sure that the patient uses the syringe 
properly at home, you must give the necessary instruc- 
tions. Many cases of otorrhoea are not cured, simply 
because the syringing is not properly performed; that is, 
the secretion is not removed. The syringing must be 
done slowly, and without force. We should especially 
avoid employing force in inflammations of the deeper 
parts; for, these having become relaxed by the suppura- 
tive process, may easily suffer injury. It is not to be 
doubted a priori, that a softened membrana tympani can 
be broken through by too strong a stream of water, and 
the ossicula auditus loosened from their connection with 
a carious cavity of the tympanum, and that the corroded 
walls may meet with further damage. I have also seen 
cases that confirmed the opinion, that, even when the mem- 
brana tympani is not relaxed, syringing, ever so carefully 
performed, may excite a feeling of nausea, of dizziness, or 
a slight fainting fit, although, according to the invariable 
statement of patients, there was no pain from the opera- 
tion. There can be but one object in syringing the ear, 
and that is the removal of something from it ; be it pus, 
inspissated cerumen, or any kind of a foreign body. When 
the examination has not shown that there is something to 
be removed, we should not attempt syringing. You may 
wonder that I say this to you, when it seems to be an 
axiom. You will be still more surprised, when, in your 
practice, you find that almost every aural patient, who has 
not come to you at first, has been ordered to syringe the 
ear. The patients who tell you this, will often very earn- 
estly and truly inform you that nothing was removed. 

You see, then, that many physicians employ syringing 
as a means of diagnosis, in order to learn if the deafness 
do not depend on a collection of cerumen. This latter 
named affection is one which plays a great part in the 
"probable" diagnoses of the profession. 



94 SYRINGING THE EAR. 

A great deal of injury is often added to the original 
trouble by such careless injections, especially if they be 
made too briskly, or if, as is sometimes practised, very 
strong tea is used as an injecting fluid. I have seen in- 
flammations of the auditory canal and of the membrana 
tympani arising from such causes. We should never use 
cold water, but only that which is lukewarm, in injecting 
the ear ; the part being intolerant of anything cold. Any- 
thing more than water is scarcely ever necessary. 

(In New York, hard rubber syringes are almost invari- 
ably used for syringing the ear. I use one having a capacity 
of about four ounces, such as is depicted in the accompa- 
nying cut. There are practically no objections to its use 
in my hands, but, on the contrary, many advantages, from 
the powerful stream, which may be made as gentle as re- 
quired by pushing the piston very slowly. Professor von 
Troltsch also uses this syringe occasionally, as a foot note 
in the original states. 

Fig. ii. 





India rubber ear syringe. 

In syringing the ears of very nervous patients, or those 
having very tender ears, it is well to fill the concha with 
warm water from the syringe before injecting it into the 
canal. We thus prepare the patient for the shock of the 
stream of water as it strikes upon the drum. 

Professor E. H. Clarke, of Boston, who has had many 
years of successful practice in the treatment of diseases of 
the ear, advises the use of an ear douche, a representation 
of which is here given, in the following language: "But 
simpler, better and less costly than any syringe, is an ear 
douche, which I have modelled after the plan of Dr. 
Thudichum's (Weber's) aural douche. It consists of a glass 



FURUNCLES IN THE AUDITORY CANAL. 95 

jar, to the side of which, near the bottom, a flexible tube 
is attached. The jar holds about half a pint. The tube 
is three or four feet long, with an appropriate nozzle. 

Fig. 12. 




Clarke's ear douche. 

cc In order to use the douche, it is only necessary to intro- 
duce the nozzle into the orifice of the meatus, and then 
raise the jar to a hight sufficient to send a current of water 
through the pipe into the ear. By this means a steady 
and continuous current is secured. It may be made gentle 
or forcible by elevating or lowering the jar. It cleanses 
the ear thoroughly and painlessly." * 

In addition to the syringe, or when that instrument can 
not be used, a steel probe, roughened at the extremity, 
about which cotton is twisted, forms an excellent means of 
cleansing the ear from pus, blood, &c. St. J. R.) 

Follicular Abscesses or Furuncles. — Furuncles of the 
auditory canal correspond exactly in their nature, to the 
furuncles which so commonly appear in other parts of the 
body. It is well known that this form of abscess is dis- 
tinguished from other purulent collections, in that the 
furuncle has in its center a circumscribed "core," which is 
formed from dead connective tissue, and generally from a 
diseased hair follicle. The inflammation generally begins 
in the hair follicle ; and as a consequence of the profuse 
formation of pus, this follicle, as also the connective tissue 

1 Observations on the Nature and Treatment of Polypus of the Ear. By E. H. Clarke, 
M. D. Boston, 1867. 



96 FURUNCLES IN THE AUDITORY CANAL. 






about, is destroyed. A so called demarcated, or circum- 
scribed inflammation develops itself about this "core," 
and thus furnishes still more purulent matter from the 
adjacent subcutaneous connective tissue. Since, however, 
the central mass of connective tissue becomes fully sepa- 
rated, the furuncle presents a great similarity to an abscess. 
These circumscribed abscesses may be described as swell- 
ings of varied size, flattish round in shape, of firm consist- 
ence, with broad bases, and without a well defined border. 
They proceed from the integument of the auditory canal, 
and are covered by it. Their color is often scarcely changed 
from that of the skin, it is seldom more than a pale red. 
They are always very tender to the touch. The surround- 
ing parts are more or less swollen, so that a complete closure 
of the auditory canal, and with it hardness of hearing, or 
deafness, may occur. Sometimes the margin of the swelling 
is so illy defined, or the meatus auditorius externus is so 
extremely fissure-like, that it is with great difficulty, that 
we can find and designate the exact position of the abscess. 
Several furuncles not unfrequently appear near each other, 
whereby the symptoms are considerably increased in se- 
verity. 

Symptoms. — The subjective symptoms from such folli- 
cular abscesses are as various as those occurring in other 
parts of the body, according to the position and extent of 
the inflammation. Sometimes the patient experiences little 
more than a troublesome sensation of fullness and of pres- 
sure in the ear, which feels very warm and as if stopped up. 
Again, severe pain occurs, extending from the ear to all 
the surrounding parts, in chewing, speaking, and in 
other movements of the under jaw; and this pain always 
increases at night. The patient complains of a feeling of 
extreme tension in the ear, of a continuous sensation of 
pounding and hammering in the head ; and he cannot lie 



FURUNCLES IN THE AUDITORY CANAL. ()J 

on the affected side, because at each contact with the ear and 
its surrounding parts unbearable pain is occasioned. In 
such cases, the unrest and excitement easily change to a 
state of fever; and I have been before now called to 
patients, whose countenance and statement would have 
induced me to fear that they were suffering from inflam- 
mation of the middle ear, instead of simple furuncle of 
the auditory canal. 

The symptoms are often very different, even when the 
inflammatory symptoms are equally distributed over the 
auditory canal. This is chiefly owing to the peculiar forma- 
tion of the lateral section of the meatus, which, as you 
remember, possesses in part cartilaginous walls, and in 
part consists only of membranous tissue, and has an os- 
seous margin, while it is also contiguous to soft parts. 
Furthermore, on the upper wall a gusset-shaped piece 
of integument extends to the osseous wall of the canal, and 
this has just as dense connective tissue- as any other part, 
as well as glands and hairs. If, now, furuncles should occur 
in such a position, where the inflamed, swollen, connect- 
ive tissue cannot extend itself, and quickly reaches a 
firm, unyielding basis, viz., the bone, the symptoms de- 
pending on tension of the connective tissue will be much 
severer, while if we reverse the case, such follicular ab- 
scesses will be little noticed if situated at the entrance of 
the auditory canal, or in similar favorable localities. 

Furuncles of the auditory canal appear at every time of 
life, and in the most different kinds of constitution. They 
often occur as complications of otorrhoea, when the ear 
is very frequently syringed, and also when the affection 
is left entirely to itself. Ear drops of a solution of alum 
appears to produce them, as well as all ear drops which have 
remained too long in the canal. (I am not able to confirm 
the view of the author, that solutions of alum have any 
particular tendency to produce furuncles ; but I have found 

J 3 



98 FURUNCLES COURSE — PROGNOSIS. 

them occurring after the use of other astringents, quite as 
frequently as after the use of alum. St. J. R.) 

A young medical man whom I treated for an obstinate 
case of chronic inflammation of the membrana tympani, 
with purulent discharge, and whom I advised the use of 
the above named astringent, and in order to produce a 
full effect to leave it in the ear during the whole night, 
closing the ear and sleeping on the other side, had regularly, 
as often as he tried the remedy, a small abscess in the au- 
ditory canal, while he could use the same astringent for 
months, if he left it in but a short time. Chronic squamous 
eczema of the auditory canal is a not unfrequent cause of 
furuncles in the meatus. The eczema, on account of the 
constant itching connected with it, causes the patient to 
irritate the integument with a hard or pointed substance, 
and thus it is brought into a state of irritation. 

Course. — Resolution sometimes occurs without any dis- 
charge of pus. Generally, however, a thin yellow point 
gradually forms, and an opening follows in three to six 
days from the beginning of the attack. Then the scene 
ends, and at one stroke all the disturbing symptoms dis- 
appear, if a new furuncle does not immediately arise. The 
contents are generally a few drops of thick pus, and a fatty 
or flocculent mass, which we can commonly obtain only 
by pressure on the walls of the abscess. It is important 
that this "core," or nucleus, which consists of dead tissue, 
should be removed, because it may easily produce renewed 
irritation and inflammation, and because without this re- 
moval the pus cannot be thoroughly evacuated. The 
discharge of pus soon ceases. Just before the opening 
occurs, we find the surface of the tumor covered with a 
smeary fluid. 

Prognosis. — The prognosis may be considered as a 
thoroughly good one, excepting therefrom the fact, that 



FURUNCLES TREATMENT. 99 

many such abscesses quite often follow each other in a 
more or less rapid succession. It is well, then, to say this 
to the patient if only one has occurred. This frequent 
return of such abscesses, causing them to continue, even 
through a long period of time, may become in the highest 
degree annoying, and a real source of trouble, although in 
themselves they are unimportant, and without unpleasant 
consequence. I once treated a man, who for twelve years 
long, with intervals of two weeks, and at the highest two 
months, suffered from such furuncles, now in one, now in 
the other ear ; and with which there was always general 
febrile disturbance, so that at each attack he was obliged 
to lie some days in bed. He was thus, on account of this 
affection hindered in his business, which was that of a 
cattle dealer. Nearly all persons who suffer from fre- 
quently recurring, year long continuing furuncles in the 
auditory canal, are in other respects entirely well ; some of 
them even of strong constitution, in the prime of life. 
Thus far, I have seen more females than males thus af- 
fected. (I have generally observed that furuncles occur 
in subjects in whom the nutrition is somewhat impaired. 
The administration of iron or some other tonic, regulation 
of the diet, exercise in fresh air, etc., is of course required 
in such cases. There are exceptions to the rule, however. 
St. J. R.) 

Treatment. — Wilde speaks highly of the use of nitrate 
of silver as an abortive remedy. When the inflammation 
has just begun, he thinks that he has by this means often 
cut the short the process, and prevented the formation of 
pus. I have seen the development of furuncles arrested 
by pencilling them with a strong solution of sulphate of 
zinc, 3ss to 3i to the ounce of water. Such a method 
of treatment is always worth the trial, although we should 
not forget that resolution without suppuration may occur 



IOO 



FURNICLES TREATMENT. 



without any treatment. Warm, fluid applications are of 
service in these cases, because they decrease the tension, and 
hasten resolution. We may fill the ear with warm water 
when it is possible to do so, and place small cataplasms upon 
the ear, or let the steam from a vessel of warm water stream 
against the affected part. (This last named will be found, 
I think, the most efficient and soothing remedy. Let some 
aromatic infusion be made, as for instance of catnip (cata- 
ria). The steam of this will be very grateful. One of the 
many nebulizers may also be used for the purpose of ap- 
plying a stream of steam to the ear. St. J. R.) A popular 
remedy, which sometimes does well, is the application of 
raisins cooked in milk. Others recommend bits of salt 
pork, which should be first freshened in water. If any con- 
stitutional disturbance exists, give a saline cathartic. I 
have not generally found leeches necessary. If used, they 
should be applied on the meatus, just in front of the tragus. 

I incise the furuncle as quickly as possible, not waiting 
by any means for the formation of pus. The quicker we 
use the knife the better. If a complete abscess has formed, 
the pus is discharged, and all the pain ceases therewith. If, 
however, it has not gone so far, the process is generally 
cut short, or at least further severe pain is spared the pa- 
tient. The incision should be deep and free. The skin 
of the cartilaginous part of the auditory canal is very dense, 
and somewhat thick ; therefore the knife must be used 
with some force. A slender, sharp pointed scalpel, with a 
long handle, which has on the other extremity a Daviel's 
spoon, such as is used in extraction of cataract, with which 
to complete the emptying of the abscess, has proved very 
serviceable to me in this and similar incisions. 

The little spoon can be used instead of a probe in finding 
the situation of the abscess, which cannot always, as has 
been already shown, be discerned with the eye. If we have 
found the most painful spot, this is the one to be cut, and 



FURUNCLES TREATMENT. IOI 

the instrument should be immediately reversed, and the Fig. 13. 
incision made without giving the patient the pain of await- 
ing it. The cutting does not cause half so much pain as 
the knowledge that the next thing is to be the cutting. 
Great relief is experienced immediately after a rightly located 
incision, even when no pus is evacuated, through the re- 
laxation of the parts, and also from the blood-letting, 
which is sometimes not inconsiderable. We immediately 
inject warm water into the ear after opening the abscess, 
in order to expedite the removal of blood and pus, and 
advise the patient to continue the applications of warm 
water, in order that the swelling may entirely disappear. 
You will, of course, understand that you are not to make 
an incision, which is always a painful thing, if the patient 
is scarcely troubled on account of the furuncle, and if you 
see from its situation that it will cause little inconvenience. 
Always advise patients who have suffered from furuncle 
to visit you a week later, or to carefully syringe the ear at 
about that lapse of time ; because, after a furuncle, and 
still more, after a series of them, increased secretion of 
epidermis and cerumen occurs, which may cause a closure 
of the auditory canal. It is also possible that this dis- 
charge may induce the formation of subsequent abscesses, 
perhaps through irritation of the hair cysts or stoppage of 
the exit of the ceruminous glands. It is entirely wrong, 
however, to do as many patients are advised ; that is, syr- 
inge the ear without cause, after furuncles have been present. 
(Too much stress cannot be laid upon the necessity for 
early incisions in these cases. The patients will thank 
you for them, and condemn those who attempt to wait 

r ! , . . , . , Scalpel, and 

for a natural opening, as so many physicians are inclined Dawr* 
to do. St. J. R.) In the case of some patients, the use of sp 
an ointment of white precipitate, with occasional syringing 
of the ear, seems to prevent these attacks of furuncles. 
We should always, in the interval of their occurrence, 



oon. 



102 FURUNCLES TREATMENT. 

observe if the integument be in a perfectly normal condi- 
tion, and if there be a squamous or impetiginous eczema 
present. By its treatment, relapses of the follicular inflam- 
mation may be prevented. 

I have tried the mineral springs, and other constitutional 
remedies to prevent the return of furuncles, but as yet I 
have found them of no effect. I would most recommend 
the internal use of Fowler's solution. 

Verneuil 1 has very lately called attention to the occurrence of ab- 
scesses of the sudoriparous glands (abces sudoripares), which are usu- 
ally confounded with furuncles. These abscesses occur most frequently 
in the axilla, on the arms, and about the nipple ; but also occur in 
the auditory canal, when they proceed from the ceruminous glands. 
Since these latter, like the other sudoriparous glands, lie in the deepest 
layers of the skin, the inflammation always proceeds from within out- 
ward. These peculiar abscesses are said to be easily distinguished 
from furuncles by their extremely well defined boundary and cylin- 
drical form. In the auditory canal, where they usually occur after 
some irritation, pruritus for example, they are said to be distinguished 
by the fact, that only a small spot is very sensitive to pressure. 

i Archives gener de Medecine, 1864, II. 






LECTURE VIII. 

DIFFUSE INFLAMMATION OF THE AUDITORY CANAL, OR OTITIS 

EXTERNA. 

Periostitis of the auditory canal, as a rule, not an independent pro- 
cess ; different causes for otitis externa ; acute form, with its 
subjective and objective symptoms; differential diagnosis; 
the chronic form. 

Gentlemen : Since in our last lecture we considered the 
circumscribed inflammation of the auditory canal, follicular 
abscesses, or furuncle, we come naturally, to-day, to speak 
of the diffuse inflammation of the same part, or of otitis 
externa. This is a form of inflammation which occurs in 
the superficial layers of the integument of the auditory 
canal, and which generally involves the entire surface of 
the canal, together with the outer surface of the membrana 
tympani. 

I think that we shall obtain a better practical and 
objective estimation of the disease as presented by the 
cases, as well as a stricter anatomical basis by grouping to- 
gether the various forms of diffuse inflammation of the 
auditory canal, under the common name of otitis externa. 
In order to a better understanding of the nomenclature 
here adopted, allow me to say, that by otitis interna, I 
understand the purulent catarrh of the middle ear, or of 
the cavity of the tympanum. The simple mucous catarrh, 
I call simply aural catarrh. By otitis, I understand all 
forms of inflammation, which cannot be considered as per- 
taining to one particular part of the ear. (The author's 



104 OTITIS EXTERNA. 

nomenclature of the inflammations of the ear, as here 
given, and as will be subsequently developed, is as follows, 
in the order met with in this book : 

i. Furuncles in the auditory canal, or circumscribed in- 
flammation. 

2. Otitis externa, or diffuse inflammation. 

3. Myringitis, or inflammation of membrana tympani. 

4. Aural catarrh, or mucous catarrh of the middle ear. 

5. Otitis interna, or purulent catarrh of the middle ear. 

6. Otitis, or general inflammation of the various parts of 
the ear. 

7. Nervous deafness. St. J. R.) 

Some authors, among whom are W. Kramer and Rau, 
divide the inflammations of the auditory canal into those 
of the cutis and the periosteum. Definite observations 
on a primary, isolated inflammation of the periosteum of 
the auditory canal, have not yet been presented, so far as I 
know. The cases which are reported under this name, are 
long standing affections, in which nothing at all can be 
shown to indicate that the affection of the periosteum was 
the primary one. On the contrary, we may often observe 
inflammations of the integument of the auditory canal, 
which afterwards produce affections of the bone lying 
beneath. It seems to me much more probable, according 
to my experience, that the periostisis is always a conse- 
quence or result of a severe and neglected inflammation of 
the cutis. Not only do clinical observations lead to such 
a view, but the anatomical facts also indicate it. Cutis 
and periosteum are generally so intimately connected with 
each other in the bony portion of the canal, that the latter 
can scarcely be isolated, and is certainly more easily sepa- 
rated from the bone than from the cutis. In consequence 
of the close connection of these two parts, every intense 
inflammation of the cutis of the osseous portion also has 



OTITIS EXTERNA SYMPTOMS. I05 

its effect upon the bone beneath, and may even produce 
inflammation, and subsequent caries. 

Many writers, among whom are Toynbee and Politzer, 
speak of a catarrhal inflammation of the auditory canal. 
The integument is certainly always thinner and more deli- 
cate, the nearer it is to the membrana tympani ; but this 
does not make it a mucous membrane. The name catarrh, 
according to common nomenclature, pertains only to affec- 
tions of the mucous membrane ; hence its use for inflam- 
mations of the external auditory canal is not proper, and 
the name aural catarrh should only be used for the middle 
ear, which is actually covered with a mucous membrane. 
Itard speaks of a "catarrhal otitis externa," and of a 
"purulent otitis externa;" a classification equally impro- 
per with the one of which we have just spoken. The 
only distinctions we are able to make are between an acute 
and chronic diffuse inflammation of the external auditory 
canal. 

Symptoms. — Otitis externa is a disease, which has no 
distinct type, but is an extremely polymorphous affection. 
Sometimes it occurs entirely unnoticed, and runs its course 
without any marked effect, either locally or constitution- 
ally, and disappears without treatment. Just as often it 
appears suddenly, and with very disturbing and disquieting 
symptoms, which are not only felt in the ear, but which place 
the whole system in a febrile condition, often continuing 
a long time, then disappearing and returning, each time 
bringing with them a deeper affection, and making life a 
burden, on account of the severe pain, and even putting 
the patient's existence in danger. Each inflammation of 
the ear may reach such a point of danger. It is, therefore, 
wrong that any presumptive unimportance should lead us 
to regard such affections lightly in the outset, as is very 
frequently done, especially in practice among children. 

14 



Io6 OTITIS EXTERNA CAUSES. 

We should never neglect the treatment of otitis externa ; 
because, together with a certain degree of impairment of 
hearing, a purulent discharge from the ear almost always 
remains after it has run its course. 

It is an affection which may appear in every time of life. 
It occurs far more commonly, however, in childhood and 
infancy, and by no means unfrequently in the first weeks 
and months of life. Rau calls attention to the fact, that 
each new cutting of the teeth in some children, is accompa- 
nied by irritation of the cutis of the external auditory canal. 

Causes. — The causes of otitis externa are very different 
in different cases. It may occur from acute and chronic 
exanthemata, which extend from the integument of the 
face to that of the ear. Thus, measles, scarlet fever, and 
small pox, not only attack the ear from within, from the 
mucous membrane, but also from the integument. The 
eczematous eruptions of the face and of the auricle may be 
transplanted in the canal or occur independently and pri- 
marily. I have more than once observed in patients with 
constitutional syphilis, broad, moist condylomata appear- 
ing on the meatus auditorius ; and after this had occurred 
a mild form of inflammation and purulent discharge from 
the auditory canal gradually appeared. At the post mortem 
of one patient, suffering from pemphigus, I found that the 
skin disease had extended to the auditory canal, and to the 
membrana tympani. 

Otitis externa occurs quite as often from irritations, and 
injuries of various kinds acting from without. Some ladies 
are in the habit of dropping Cologne water in the ear for 
the relief of toothache, as recommended by Malgaigne ; 
and by this means diffuse inflammation may be excited. 
I saw a case of inflammation, arising from frequent and 
long continued injections of the ear with warm chamomile 
tea, which were ordered and too faithfully carried out, for 



OTITIS EXTERNA CAUSES. IO7 

impaired hearing arising from another cause. I have also 
seen otitis externa occur after actual scalding and burning 
the canal from very hot fluids. The affection may also 
occur after foreign bodies have been removed with an 
unnecessarily great degree of force ; a matter upon which 
we shall speak more explicitly at a subsequent time. 

Cold upon the ear, as for instance a draught of air blowing 
upon the head, when it is near a broken window, or the 
introduction of cold water, are frequent causes of otitis. 
Cold is not generally well borne by the ear, and we should 
protect it more than is generally done. We shall recur to 
this subject also in speaking of acute inflammation of the 
membrana tympani. (The traveler in Germany cannot fail 
to observe the great prevalence of the habit among the people 
of all classes, of stuffing the ear with cotton, even in the 
mildest weather. I believe that this is about as sensible a 
practice as stuffing the nostrils would be; the natural curva- 
ture of the auditory canal being protection enough from the 
open air. The cartilage of the ear will be frozen before 
the membrana tympani or canal will be inflamed by the 
contact of cold air, provided it does not reach it through a 
narrow aperture, as in the case of a broken or slightly 
opened window. Ladies formerly covered their ears with 
their hair or bonnet, and the amount of deafness was just as 
great among them as with the other sex. I do not believe 
there is a case on record, where inflammation of the ear 
has resulted from leaving the meatus uncovered in an open 
cold air. If the body becomes chilled, or the feet wet, or 
a narrow draught of air blow directly upon the head, in- 
flammatory action may result. It is thus that cold becomes 
one of the causes of deafness. Of late, so called ear muffs 
are used to protect the ears. They are very useful for cases 
of inflamed or irritated ears, or for those that are very 
sensitive to the cold, and much better than cotton plugs. 
St. J. R.) All fluids placed in the ear should be previously 



Io8 OTITIS EXTERNA CAUSES. 

warmed, lest they excite unpleasant, if not positively inju- 
rious effects. 

A new variety of otitis externa has been lately described 
in the Archiv. fur Ohrenheilkunde^ by Schwartzes and also 
by Wreden. It is caused by a vegetable parasite, asper- 
quillus glaucus, and is particularly obstinate. Dr. Schwartze 
says : " It appears to be very probable that this vegetable 
parasite is more frequently a cause of the obstinate, fre- 
quently relapsing, and chronic inflammation of the external 
auditory canal than is generally supposed." Wreden re- 
ports six cases, in great detail. Mapper reported a case in 
1844 of these mushroom growths; and Pacini in 1851. 
The microscope must be used in order to detect the true 
nature of the growth. The forceps are generally necessary 
to remove the white lardaceous mass. Solutions of tannin 
and lead were most successful in restoring the normal con- 
dition of the canal. It is probable, according to Sckwartze, 
that exudative inflammation occurred in the canal before 
the occurrence of these mushroom growths. 

And at times we are not able to find a cause for the occur- 
rence of diffuse inflammation of the auditory canal. Such 
cases occur very often in children, as well in those who are 
healthy as those who, on account of the swelling of the 
cervical glands, eruptions on the skin, coryza, and other 
forms of catarrh, are denominated scrofulous. I cannot 
warn you enough, gentlemen, from the too frequent use 
of the diagnosis scrofulous. It is, among too many, a 
convenient expedient to avoid a local examination, and a 
tedious and wearisome local treatment of the affected por- 
tion. The diagnosis "scrofulous" plays a great and fatal 
part in diseases of the ear ; and yet the chief foundation for 
it, the enlarged cervical glands, are often only consequences 
of neglected discharges from the ear. If the otorrhoea be 

1 Archiv. fur O., II, S. 5. 



OTITIS EXTERNA SYMPTOMS. IO9 

treated and arrested, the enlarged glands also disappear. 
We do not find catarrh of the cavity of the tympanum as 
a complication of otitis externa in any cases as often as 
in those where the otitis externa appears spontaneously 
in childhood ; but in children, affections of the integument 
and of the mucous membrane very often occur simultane- 
ously. The causes are very numerous ; so that the friends 
of classification and sub-classification array a great list of 
them. Thus the otitis may be classified according to the 
degree of the affection, and its severity, as erythematous, 
erysipelatous, and phlegmonous ; according to the ascer- 
tained constitutional affection, morbillous, scarlatinous, or 
variolous, as scrofulous or syphilitic, rheumatic, parasi- 
tic, etc., etc. 

All these various forms do occur ; and it cannot be de- 
nied that the course of the affection may be very much 
modified by the cause. For practical purposes, however, 
such sub-classifications are of no use to us, and you need 
not confuse yourselves with their recollection. 

Symptoms. — These we see from the foregoing, differ 
according to the exciting causes, their variety and intensity. 
In the acute form of diffuse inflammation of the auditory 
canal, the patient usually complains in the beginning of an 
itching sensation, with a feeling of heat and dryness in the 
ear ; which itching is so great in some cases that he can 
scarcely be prevented from using some kind of an instru- 
ment, an ear spoon, pin, or the like, to alleviate it. The 
relief of the itching thus obtained soon becomes painful, 
however ; and without any such treatment of the parts, 
the morbid sensitiveness increases to a dull feeling of un- 
easiness in the ear, and gradually to a severe, penetrating and 
tormenting pain, extending deeply into the organ, almost 
always increasing by night, and leading to loss of sleep, 
febrile disturbance, and even to a mild form of delirium. 



IIO OTITIS EXTERNA SYMPTOMS. 

In severer cases this pain, felt in the deeper parts of the ear, 
extends to the surrounding parts, or even over the entire 
half of the head. It is increased by every motion of the 
body, and still more of the head, by sneezing or coughing, 
and at every vigorous movement of the lower jaw, espe- 
cially in chewing or yawning. Such pain occurs the more 
readily, the more the anterior auricular region is swollen, 
or the more the cartilaginous portion takes part in the 
inflammation. 

In milder cases the vicinity of the ear is rarely swelled 
to any extent, but is frequently very sensitive to pressure. 
Any motion of the meatus excites pain, especially drawing 
upon it. For this reason, the aural speculum should 
always be introduced slowly and with care. 

The hearing of the affected side will be affected in pro- 
portion to the participation of the outer surface of the 
membrana tympani in the inflammation. It, is always 
more or less involved in a case of otitis externa. If we 
examine the auditory canal at the beginning of the attack, 
we find the epidermis with the surface of the drum greatly 
injected and swelled. In this statement we are excluding 
the changes produced in individual cases by an exanthema 
or injury. The injection and hyperaemia show themselves 
more clearly on the membrana tympani, and its immediate 
vicinity, because, in the other parts of the canal, the con- 
gestion is concealed by the thicker layer of epidermis, 
whose saturation and relaxation prevent the abnormal vas- 
cularity of the subjacent cutis from being seen. 

After the congestive stage has lasted two or three days, 
an exudation appears. In the beginning it is of a white 
color, watery in consistence. A little later on, it becomes 
a kind of mucous secretion ; and at last, it is yellowish 
pus. Coincident with the appearance of this otorrhoea, 
which in the beginning is slight, but which is always in- 
creasing, the patient experiences a great improvement, and 



OTITIS EXTERNA SYMPTOMS. Ill 

the pain suddenly disappears. In some cases this otor- 
rhcea is not so much a free formation of cells as a very- 
abundant desquamation ; so that in a very short time the 
whole auditory canal is filled with a white, moist, as it 
were, macerated lamella. I have observed this exudation 
oftener on the drum itself than on other parts. We can 
now, by injections or by means of delicate forceps, remove 
a number of white flakes of the size and form of the mem- 
brana tympani, which are certainly produced by its outer 
surface. Some are also of the shape of the walls of the canal. 
I have observed such desquamations chiefly in cases where 
the pain was very severe and extensive. The pain and 
importance of the affection are the greater, the more the 
membrana tympani and deeper parts are involved. 

If we make an examination at a later period of the mor- 
bid process, or during the stage of exudation, the canal 
must be previously cleared by injections or pencillings. 
If the syringe be very large, and the stream very strong, 
it is easy to perforate the membrana tympani. On account 
of the great amount of swelling and infiltration, it is diffi- 
cult to appreciate the condition of the different parts of 
the canal, especially the deeper ones ; their appearance and 
relative position being greatly changed. The examination 
is also often made more difficult, on account of the amount 
of the seeretion adhering to the wall, and on account of 
the saturated scales of epidermis which are in the caliber 
of the canal, and which can only be removed after some 
time has elapsed. 

But apart from such hindrances to a complete view of 
the parts, the auditory canal appears slightly contracted on 
all sides. The line of demarcation between the margin 
of the membrana tympani and the end of the meatus does 
not distinctly appeal* The epidermis on both parts is 
relaxed, saturated and swelled, and the surface is covered 
with a purulent deposit in certain spots ; while in other 



112 OTITIS EXTERNA SYMPTOMS. 

situations the integument is removed. Where the latter 
has occurred, an evenly red, often only slightly swollen 
surface is seen, on which we are not able to distinguish in- 
dividual vessels, and which resembles a granulating wound, 
or a blennorrhceic conjunction. These spots, in which the 
process of throwing off epidermis has begun, are frequently 
covered by isolated bits of epidermis, or by a thin layer 
of pus, which, when removed, are replaced almost under 
our eye. 

After the purulent discharge has once appeared, a stage 
which is very welcome to both physician and patient on 
account of the cessation of pain, it always continues for a 
time ; but under favorable circumstances, it may gradually 
abate, and even entirely cease without any treatment. It 
more frequently becomes chronic, however, if it be not 
treated, and lasts for years, with varying degrees ofseverity, 
and may even continue throughout the whole life, with 
occasional interruptions. Quite a proportion of the cases 
of otdrrhcea, coming under treatment, may be referred to 
such an inflammation of the auditory canal as their starting 
point. 

In the beginning of a painful inflammation of the audi- 
tory canal, or when it has become impossible to examine 
the more deeply situated parts, it is not always easy to 
decide whether we have a circumscribed inflammation, 
proceeding from a follicle or gland, or one of the diffuse 
variety. The latter acts more upon the superficial integu- 
mentary layers, but very soon causes a symmetrical satura- 
tion of the epidermis, and a concentric but rarely very 
great contraction of the passage. In the furuncular variety 
of inflammation, which involves the deeper layers of the 
cutis, and especially the cartilaginous meatus, the swelling 
is somewhat more localized, and projects forward into the 
meatus from one point. 

If the membrana tympani can be examined, its outer 



OTITIS EXTERNA — SYMPTOMS. I I 3 

surface will be found in a corresponding condition to that 
of the canal, if the case be one of otitis externa. If, how- 
ever, there is only a circumscribed furuncular inflammation, 
there only occurs a saturation of its coating of epidermis ; 
and this takes place at a later period. The impairment of 
hearing in the furuncular variety of inflammation, increases 
in proportion to the mechanical closure of the meatus. In 
otitis externa it depends upon the amount of thickening in 
the membrana tympani. In the latter form, suppuration 
is apt to occur rather earlier than in the former. 

Besides these two varieties, certain mixed ones may 
occur, as, for example, extensive phlegmonous inflamma- 
tions of the sub-cutaneous cellular tissue, after severe 
injuries. I should also mention that secondary abscesses 
occur also in the auditory canal in suppurative inflam- 
mation of the middle ear. These extend to the glands 
already described as existing in the upper and posterior 
wall of the osseous meatus. 

I shall take occasion to speak more in detail of this form 
of abscesses, which are very frequently mistaken for furun- 
cles, when we come to speak of the different kinds of 
otorrhcea. 

Very often, however, the patients who present themselves 
with otitis externa do not speak of such a painful and acute 
origin ; the affection has begun more insidiously. Such 
a chronic form of disease is quite as common as the cases 
which are developed from the above described acute variety 
when left to itself, or from those which are not at once pro- 
perly treated. They occur most frequently in childhood. 

The subjective symptoms are at first so slight that the 
moisture of the ear first calls attention to the affection. 
Painful symptoms sometimes exhibi| themselves, however, 
even when the affection has existed for a long time with 
no more disturbance than a discharge from the ear, and 
some impairment of hearing. Sometimes the otorrhcea 

*5 



114 OTITIS EXTERNA SYMPTOMS. 

occurs periodically, disappearing, for example, in summer 
to return in the winter. In this form we find the canal 
only a little swollen, its covering softened, as if macerated, 
bleeding very readily, and covered with a secretion, or with 
brown crusts that smell offensively. Great vascular injec- 
tion is only to be observed in the deeper parts, and on the 
membrana tympani. This membrane seems flattened, its 
cutis is thickened ; and since this is densest over the mal- 
leus, the latter can scarcely be seen. The amount of the 
secretion is very various, changing according to the time 
of year and other influences. At one time the meatus is 
almost dry ; again, there is a profuse discharge of a thin, 
yellowish fluid, with an extremely bad odor, which excori- 
ates the skin around the ear and neighboring parts, and soils 
the clothes of the patient. 

I have never been able to measure the exact amount of 
the discharge in any given case; but I have seen cases 
where it was at least from three to four ounces daily. Such 
cases of profuse secretion we generally find in the case of 
children of the lower classes, or in those who are not always 
kept clean, and among whom the continuance of the filthi- 
ness is even advocated by the assertion that the disease must 
be cured by being driven out of the system from within, 
and not by " driving it in," lest dangerous internal dis- 
eases should arise. These children, who, except as to the 
ear, are often rare specimens of vigor and health, are treated 
for months and years with iodide of mercury, Plummets 
pill, laxatives, cod liver oil ; all sour and fat food, even fruit 
is forbidden them ; and as if the region of the ear were not 
foul enough, it is made more so by means of tartar emetic 
ointment, and other vesicants. In short, all conceivable 
remedies will be usec^ to cure the discharge from the ear, 
without one thought of the first surgical as well as domestic 
law, the law requiring cleanliness before all things. 

(The preceding very just remarks of the author as to 



OTITIS EXTERNA SYMPTOMS. II5 

the preeminent necessity for local cleanliness in treating 
these cases of purulent discharge from the auditory canal, 
should not be construed as countenancing any disregard by 
the physician, of the hygienic condition of the little pa- 
tients. In our city practice among half starved and badly 
fed children, huddled in crowded, unventilated, and damp 
tenement houses, we are often obliged to expend more 
energy in enforcing hygienic rules, than those who practice 
among children living in our country districts, where 
wretchedness and disease do not reach such frightful ex- 
tents as with us. A correction of the improper sanitary 
condition, does wonders in cases of asthenic inflammation 
of any organ. St. J. R.) 



LECTURE IX. 

otitis externa (continued). 

Consequences; prognosis; treatment; Vesicants, cataplasms, and 
instillations of various oils. 

Abstraction of Blood in Aural Disease* 
Choice of point of application of leeches ; precautions in their use, 

Narrowing of the Auditory canal. 
Exostoses and hyperostoses. 

Gentlemen : We may now consider the consequences 
of otitis externa, the disease whose study we entered upon 
at our last meeting. More or less thickening and opacity 
of the membrana tympani are apt to remain after such an 
affection. These changes will cause a certain amount of 
impairment of hearing. A more important consequence 
is the formation of polypoid growths in the course of a 
long existing otorrhcea, which tend to increase the secretion, 
and often cause .blood to be mingled with it. A number 
of other pathological changes occur through the irritation 
of the pus remaining upon the meatus. This finally sets 
up an inflammatory condition. The most frequent result 
is an ulceration of the membrana tympani. The affection 
which was hitherto external, extends itself to the inner 
parts ; so that from an otitis externa, a much more serious 
form of disease — otitis interna — is developed. 

On account of the great importance of purulent dis- 
charges from the ear, in a pathological and practical point 
of view, we shall, at a later period in the course of these 






RESULTS OF OTITIS EXTERNA. I 17 

lectures, devote special time to their consideration. At 
this place, however, I may call your attention to the fact, 
that not only suppurative processes of the middle and ex- 
ternal ear, but also those that are located in the external 
ear alone, may lead to the evil consequences that you have 
observed on some of the patients at the medical clinic of this 
University. I need only call your attention to the conti- 
guity and nutrient relation of the cutis and periosteum of 
the auditory canal, of which we have already spoken, and 
at the same time recall to your mind the exact situation 
of the canal with respect to other parts. (See fig. 2, p. 22.) 

Of course, the proximity of the transverse sinus, the 
dura mater and the cerebrum, as well as the fact that 
partitioned cellular osseous spaces, which in part contain 
air, and are in part diploetic, lie next to the canal, must 
have an important influence upon the course of inflamma- 
tory and suppurative processes in the ear. Such affections, 
even without any participation of the cavity of the tym- 
panum, without a perforation of the membrana tympani, 
and without any evident caries of bone, may lead to a result 
that puts the life of the patient in danger. 

Toynbee 1 details such a case of inflammation of the ex- 
ternal auditory canal, which, without perforation of the 
membrana tympani, and without any superficial ulceration 
of the bone, led to purulent menigitis. All the particulars 
are given, both of the history of the case and of the post 
mortem section. Gull z reports another case, where, in con- 
sequence of caries of the upper and posterior wall of the 
auditory canal, and where the membrana tympani was intact, 
though thickened, a thrombus occurred in the transverse 
sinus, and in the jugular vein. 

In two cases in which I« made post mortem sections, 
there were fistulous passages leading from the the posterior 

1 Diseases of the Ear, p. 63. 

2 Med. Chirurg. Transactions, XXXVIII, p. 157. 



I I 8 RESULTS OF OTITIS EXTERNA PROGNOSIS. 



wall of the auditory canal, through the mastoid process to 
the sigmoid fossa, accompanied of course by other changes 
in the deeper parts of the canal ; and in the one case, 
where there was an extensive thrombus in the transverse 
sinus, the destruction of the thrombus began where the 
fistula in the bone had opened. 

These anatomical considerations are doubly worthy of 
notice in children, where the osseous layer between the au- 
ditory canal and the brain is very thin and porous, and 
where there are numerous openings for blood vessels, which 
lose themselves in the bony substance, and communicate 
with branches coming from the dura mater. Purulent 
discharges from the ear are very common in childhood, and 
very little attention is paid them by the laity and physicians 
when thus occurring, but they are left to themselves unless 
some especial symptoms call attention to them. 

In post mortem examinations of these parts, the diplo* 
etic spaces, as well as the cerebral sinuses, are not always 
examined ; and it may sometimes have occurred that the 
true cause was overlooked, which, under the form of men- 
ingitis, pleuro-pneumonia, typhoid, or pyaemic conditions, 
led to a fatal result. Never omit, in the diseases of chil- 
dren, where the signification of the symptoms is so uncertain 
and doubtful, to examine, both at the sick-bed and on the 
post mortem table, as to the possibility of the origin of 
the trouble in the ear. 



Prognosis. — This necessarily varies in the acute variety 
very considerably, according to the exciting causes. An 
idiopathic inflammation of the auditory canal, or one pro- 
duced by some not very severe injury, allows a favorable 
prognosis, if the disease be recognized and appropriately 
treated. The secondary form, occurring in the acute exan- 
themata, often results badly, because, in the danger of the 
constitutional disease, which may be great, even threatening 



RESULTS OF OTITIS EXTERNA TREATMENT. I 19 

the life of the patient, the affection of the ear is either not 
carefully observed, or is entirely overlooked. 

The more the membrana tympani is attacked with the 
inflammatory process, and is involved in it — and this is 
often the case in the acute exanthemata, or when there is 
at the same time an acute inflammation of the cavity of 
the tympanum «=■?- the greater difficulty we shall have in 
avoiding a perforation of the membrane. However, when 
other circumstances are favorable, the perforation is not so 
extremely serious, for generally it may be healed. The 
prognosis is much more uncertain if the disease has existed 
for some time, and if important changes have already oc- 
curred, in other words, if there is a chronic otitis externa. 
As will be seen from these remarks, every otorrhcea is a 
serious matter, which is certainly dangerous to the hearing ; 
for we cannot be certain as to how much part the adjacent 
structures, viz., the vessels and bones of the ear, will take 
in the process. The prognosis in every chronic otorrhcea 
must be considered uncertain and doubtful, although the 
form which is confined to the external ear, is generally 

j cured, that is, the discharge gradually ceases, and the hear- 

t ing returns to a certain degree. 

Treatment. — The treatment of otitis externa, in the be- 
ginning of the acute form, as well as in each sub-acute 
stage of the chronic form, is an antiphlogistic one. The 
patient should remain in-doors, be placed on light diet, 
and take a saline cathartic. Leeches are almost always 
required, and those should be placed anterior to the 
external meatus. As a rule, from two to four will be 
enough ; and occasionally their application will require to 
be repeated, if the pain and other inflammatory symptoms 
continue. Next to leeches, nothing so quiets the pain as 
often filling the ear with lukewarm water, leaving it in the 
ear, the patient at the same time lying on the other side, 






120 OTITIS EXTERNA TREATMENT. 

from five to ten minutes. If suppuration has commenced 
— otorrhcea — we must above all things secure the removal 
of the secretion ; and to this end, the ear should be syr- 
inged three or four times daily. This performance is 
generally extremely pleasant to the patient, if the tempera- 
ture of the water be properly regulated, and the injection 
be made slowly. In the intervening time the patient should 
lie on the affected side as much as possible, in order that 
the secretion may have a free exit. In order that the pa- 
tient may lie on the affected side without difficulty, I 
sometimes use ring-shaped pillows with great advantage. 
The exit of the discharge may be assisted by long strips of 
lint or linen placed in the ear. These last suggested appli- 
ances are good ones to be used in all cases of discharge from 
the ear, since they cause no irritation, and perfectly absorb 
the pus, and may be renewed as often as is necessary. 

In order to diminish the secretion, you may use astrin- 
gent lotions, weak solutions of alum, acetate of lead, sul- 
phate of copper or zinc, with which you fill the canal after 
it has been cleansed. The same solutions, gradually in- 
creased in strength, should be used in the chronic form of 
the disease, and should be retained as long as possible in 
the ear. They should be always warmed, and never be 
cold when dropped in. A small reagent-glass may be used 
for warming the lotion, and prescribed with the astrin- 
gents. When there is only a slight amount of discharge, 
we may remove it by means of a camel's hair pencil. (A 
delicate cotton holder, such as dentists employ, is also a 
very convenient means of cleansing the ear. St. J. R.) 

Let us now devote a few moments to the means of 
treatment which are often recommended for otitis externa, 
but whose use I can only advise you to abstain from. 
First, then, there are blisters and irritating ointments, 
which are indiscriminately applied over the mastoid pro- 
cess, in almost every form of aural disease. In acute 



OTITIS EXTERNA POULTICES. 121 

inflammation they increase the pain and irritation ; and in 
children and persons with a delicate skin produce an eczema 
in the region of the ear. In chronic cases, however, they 
will seldom do harm, but certainly no manner of good. 
We have had full opportunity to collect experience on this 
point, since almost every patient with chronic affection of 
the ear has tested these agents in some form or other. 
Who will deny that in a case of otorrhoea, a long continued 
discharge behind the ear is an annoying affair, and a chronic 
source of uncleanness ? 

Dry heat, applied by means of warm cloths, or warmed 
cotton, which are commonly used in stilling pain in the ear, 
diminish the pain somewhat ; but it returns in a greater 
degree so soon as their use is discontinued ; and thus the 
inflammatory condition is considerably increased. Moist 
applications, such as poultices, are common among aurists 
and other practitioners. I formerly made use of them, but 
have now nearly discontinued the habit, only making use 
of cataplasms in the case of furuncles, or of entirely super- 
ficial diffuse inflammation of the canal. Nothing stills the 
severest pain in the ear so quickly, and exerts such quiet- 
ing influence. No remedy shortens the painful congestive 
stage so much as the application of poultices in the various 
forms of otitis ; since it quickly produces exudation and 
discharge, and with it cessation of tension and pain. There 
can be no question as to the truth of this experience. But 
in spite of all this, I warn you against their use in all deep 
seated inflammatory processes in the ear, because nothing 
is so adapted to produce profuse and wearying discharges 
as the application of poultices. 

Schwartze does not use poultices even in furuncles, be- 
cause he has several times observed that diffuse inflamma- 
tion of the auditory canal, and once even a perforation of 
the membrana tympani, followed their use. 

When I compare the results of my present practice with 
16 



122 OTITIS EXTERNA TREATMENT. 

those of the period when I commonly used poultices, I 
perceive a very marked difference; in that now a perforation 
of the membrana tympani seldom occurs, and the subsequent 
discharges are much less obstinate. This is a fact well 
worthy of notice in all inflammations where the membrana 
tympani is affected ; and I am of the opinion that the 
number of cases of otorrhea, and affections of the temporal 
bone, would be sensibly diminished if all inflammations of 
the ear were not so indiscriminately treated by the applica- 
tion of cataplasms. 

The practice of frequently filling the ear with warm 
water, which is a clean and interrupted cataplasm, will 
greatly diminish the pain, if not quite as much as the ap- 
plication of a poultice to the whole region of the ear; and 
from it, I have never seen any such excessive deliquescence 
and relaxation of tissues, such as very often occurs from 
the method generally practiced. 

If we refer to the analogous condition of affections of 
the eye, for a proper estimation of this practically important 
question, we know that in blennorrhea of the conjunc- 
tiva, warm applications produce destruction of tissue very 
quickly, and that we can excite an intense form of blen- 
norrhea by the use of cataplasms. In an old case of pan- 
nus, for instance, warm poultices produce almost the same 
effect as inoculation with blennorrhagic secretion. 

Finally, as to the dropping in of warm oil, which is 
practised by some aurists. It possesses no kind of advan- 
tage over the dropping in of warm water. On the con- 
trary, there is the positive disadvantage, that oil is a'kind 
of foreign body, an adhesive substance, which is not fitted 
to come in contact with an irritated surface which has been 
deprived of its epidermis. Glycerine is better, not being 
adherent, and being soluble in water, so that it can be re- 
moved by syringing. However, simple water does the best 
service. 



APPLICATION OF LEECHES. I 23 

We should also use only warm water in injecting the 
ear. Additions of milk or vegetable decoctions (chamomile 
•tea is especially employed in Germany), are not only su- 
perfluous, but positively harmful ; because in their use 
organic material is always left behind, which may easily set 
up an irritation in the ear, or may undergo decomposition. 

Local Blood-letting. — In the subsequent parts of this 
course of lectures we shall often have occasion to speak of 
abstraction of blood, and of the use of leeches in affections 
of the organ of hearing ; and I may, therefore, to-day go 
a little more into detail on this point. 

In certain aural inflammations, local abstraction of blood 
is a highly important remedy. I scarcely know any condi- 
tion where the immediate effects of treatment, especially in 
regard to the diminution of pain, are so striking as in the 
use of leeches in affections of the ear. Yet they should be 
properly employed, and certain precautionary rules adopted, 
or they will do no good, but may even cause harm. 

The mastoid process has been commonly chosen as the 
point of application of leeches in all forms of inflammatory 
affections of the ear. Wilde first called attention to the 
fact, that in most of the painful affections of this organ, 
and these are chiefly the inflammations of the external au- 
ditory canal and of the membrana tympani, a few leeches 
applied on the meatus, and particularly in front of it, 
did much more good than a much larger number applied 
behind the ear. We may often have an opportunity in 
practice to notice the comparative effect of the application 
of leeches at the two points in the same person. 

The anatomical explanation of these facts may be found 
in the course and origin of the external vessel of the mem- 
brana tympani, as demonstrated by myself. We now 
know that the external meatus and the membrana tympani 
receive the most of their vascular supply in common, from 



124 BLOOD VESSELS OF MEMBRANA TYMPANI. 

branches of the deep auricular artery, which passes off 
behind the articular process of the lower jaw, i. e., in front 
of the meatus; and that they first supply the tragus and* 
the anterior portion of the auditory canal. 

The deep auricular vein also lies in front of the meatus. 
This is the principal vein of the external ear. When we 
wish, therefore, in affections of the auditory canal and of 
the membrana tympani, to evacuate blood from a point 
nourished by the same arteries with the affected part, we 
should choose, not the mastoid process, but the meatus, 
particularly the tragus and its immediate vicinity. All 
this refers to affections of the external ear. 

The circumstances are different, however, when we are 
dealing with disturbances of nutrition, which are more 
deeply situated, when we have an inflammation in the 
cavity of the tympanum, and in the adjacent bones. In 
such cases where, however, we have not much to hope for 
from blood-letting, we may apply the leeches on the mas- 
toid process, under the ear, or near the style-mastoid fora- 
men, or even in front of the ear, since the cavity of the 
tympanum and the neighboring bones draw their blood 
supply from various sides, partly from the tympanic artery, 
which passes through the Glaserian fissure, i. e., at the arti- 
culation of the jaw, and from the style-mastoid, which 
enters under the meatus into the Fallopian canal. The 
mastoid process and the adjacent bones receive their blood 
supply from the arteries of the dura mater and pericra- 
nium, from within and without. This process is also 
penetrated by a number of vessels, which unite the external 
veins of the membranes of the brain, and the sinuses and 
veins within the calvarium, in part by an indirect connec- 
tion by the vena diploica temporales posteriores, in part di- 
rectly through the vena emissaria mastoids. 

In drawing blood from the mastoid process, we may 
cause a quick and full stream to flow by means of Tour te- 



APPLICATION OF LEECHES. I 25 

loupe s artificial leech, and may take blood not only from 
the membranes of the brain and the bones, but also from 
the veins and sinuses on the interior of the skull. 

I have still to add a few rules for the application of 
leeches on, or in front of, the meatus. You should always 
indicate the place of application with ink. If you do not 
close the auditory passage with cotton, blood will run in, 
which may coagulate there, and increase the malady of the 
patient. The leech itself may also get in. A physician 
once told me that he applied a leech to the ear which crept 
in, and caused such excessive pain that he thought it must 
have bitten the membrana tympani ; and so it remained 
for an exceedingly painful hour. I think in such cases 
we could help the matter by dropping in a solution of salt 
or a small quantity of oil. It is best, however, to prevent 
such an accident by stopping up the auditory canal. It is 
also well to tell the patient the means of arresting the 
bleeding ; for occasionally the haemorrhage proceeds fur- 
ther than is wished, especially from the temporal and 
aural region. These means are, long continued digital 
compression, pressure with punk, which, if necessary, is 
saturated with liq.ferri sesquichlorati^ or the like. I know 
a case in which a leech, placed upon the temple, was the 
immediate cause of death, in a child of two years of age, 
because those about were not able to check the haemor- 
rhage. The child died of debility a short time after, in 
consequence of the loss of blood, which was excessive for 
its tender age. After the bleeding has ceased, cover the 
bite with a piece of court plaster, or similar material. 
There are cases which react to every leech-bite, with erysi- 
pelatous swelling of the face and head. Whenever the 
wound easily becomes unclean, as for instance in otorrhoea, 
this is very apt to be the case. It is not long since that I 
saw, on a patient for whom I had ordered a leech applied, 
erysipelas, extending from the place of application over 



126 NARROWING OF THE AUDITORY CANAL. 

the whole face, and which assumed such proportions that 
it was only by the most energetic means that I could re- 
strain its progress. In this case I had every reason to 
suppose that the erysipelas arose from contact of a puru- 
lent discharge with the wound of the leech. cc Little 
causes, great effects," is a sentence whose full import is 
yet to be comprehended in the practice of surgery. Do 
not consider little things too lightly, and you will very 
often guard against great injury. 

Narrowing of the Auditory Canal. — Before we leave 
the external auditory canal, we have still a class of condi- 
tions to consider, which cause contractions or narrowings 
of the canal, of various degrees and shapes. They occur 
not only in the cartilaginous but also in the bony portion 
of the canal. 

The most frequent variety is the fissure or slit-like con- 
traction of the cartilaginous portion of the canal. The 
anterior and posterior wall, particularly at the entrance of 
the canal, lie more or less close together, so that its usually 
oval caliber is changed to a longish slit or fissure, or it is 
entirely removed. Up to this time, I have observed high 
degrees of this variety only in old persons. In one very 
marked case which I observed during the lifetime of the 
patient, and also in a section of the parts after death, the 
dense fibrous tissue which forms the upper and posterior 
portion of the auditory canal, was in a condition of ex- 
treme flaccidity, and sank towards the anterior wall. Of 
course, still other causes may produce the same result. It 
appears to me that such a flaccid condition of the fibrous 
tissue is the principal reason for the narrowing of the canal. 

The view of Larrey (pere), that the loss of the molar teeth, 
and the thereby changed position of the under jaw, caused 
the cartilaginous walls to fall together, is certainly incor- 
rect. The head of the lower jaw would rather exert a 



: 



NARROWING OF THE AUDITORY CANAL. 12J 

gradual influence upon the osseous canal ; but according 
to the examinations as yet made, such an influence has not 
been verified. 

As frequent as the slit-shaped contraction of the auditory 
canal is, it is only rarely that it increases to such an extent 
as to exert any considerable influence upon the acuteness 
of hearing. But the normal evacuation of the cerumen is 
interfered with by this condition, and therefore accumula- 
tions readily occur, especially in old people. Persons, 
whose impairment of hearing depends upon this falling 
together of the walls of the canal, hear better as soon as 
the auricle is drawn back, or when the speculum has been 
introduced. 

The* so called "Abrahams" — small silver or golden 
tubes, with a funnel-like expansion, so often found in use 
among those partially deaf — are useful alone in these cases 
of collapse of the meatus, although they are recommended 
for all forms of deafness. They are very readily bought 
by patients, on account of their small size, and the fact that 
they are scarcely noticed when worn. Senile deafness, at 
least of a high degree, depending on this collapse of the 
walls of the canal, is very rare however. N I have only as 
yet observed a very few typical cases of this sort. 

A ring-like, or annular contraction of the walls of the 
canal on all its sides is occasionally observed as a congenital 
anomaly of development. I once saw a case of this kind 
in a boy, existing on both sides to such a degree that at 
first I thought it was a case of congenital closure of both 
auditory canals. The patient understood low-toned con- 
versation at several feet distance, so that he was able to be 
educated at college. He could only hear a watch, how- 
ever, which should be heard at five feet by a normal ear, 
when it was laid upon the auricle. He could hear it better 
when laid upon the adjacent bones. On closer examina- 
tion, it was seen that the cartilaginous part of the ca^fal 



128 NARROWING OF THE AUDITORY CANAL. 

extended inward like a funnel. On drawing the walls 
apart, at the apex of this funnel, a narrow canal was found. 

This canal was somewhat larger on the left side than the 
right, so that a probe of one-half a millimetre in thickness 
could be introduced, although it caused some pain. Since 
this dilatation caused the patient to hear much better, I 
advised a methodical continuation of this treatment, but I 
never saw the patient again. 

In another case, I saw a similar although not so great a 
contraction, also beginning at the meatus, and on one side 
only. There were also two elevated brownish-colored spots 
just in front of the tragus; in which position, at the 
time of birth, there had been a small lobule, which had 
been removed by ligation some time before. These con- 
tractions of all the sides of the canal are more frequently 
the result of thickening of the integument, such as often 
occurs after frequent or chronic inflammations of the audi- 
tory canal. In one case, I saw such a contraction of the 
caliber of the canal, caused by the -frequent occurrence of 
furuncles, which always appeared on this one ear alone. 
It is most frequently caused by chronic eczema, which, in 
consequence of the thickening of the integument, changes 
the auricle to a misshaped structure, and more or less 
lessens the size of the auditory canal. Occasionally it 
completely closes it. This condition may be generally 
relieved by the well known treatment of the eczema, with 
astringent fluids, or still better with ointments of zinc, or 
of white or red precipitate. These are pencilled upon the 
affected parts. 

In one case in which the soft parts had become so thick- 
ened, that the almost closed canal could only be entered 
by a very delicate probe, I succeeded in dilating the pas- 
sage to such an extent, by the daily application of com- 
pressed sponge, as to enable me to examine the deeper 
parts with an aural speculum, and to treat the chronic 



EXOSTOSES AND HYPEROSTOSES. I 29 

otorrhcea interna from without. Recently I have used 
laminaria digitata, as a means of dilatation with great ad- 
vantage. 

Exostoses and Hyperostoses. — Three forms of contrac- 
tion occur on the bony portion of the canal. The most 
frequent variety, but one that never exists to a very 
high degree, consists in a great projection of the anterior 
wall, close to the membrana tympani. It occurs at every 
time of life, and is by no means limited to persons without 
teeth. When the auditory passage is thus encroached upon 
we can scarcely ever, however much we pull back the auri- 
cle, or push the speculum upward, see the anterior and 
lowest portion of the membrana tympani, or the peri- 
phery of the triangular light spot. This hindrance to a 
full view of the membrana tympani is, so far as I know, 
the only influence which this abnormal condition of things 
exerts upon the ear. 

Exostoses of the auditory canal are by no means of 
unfrequent occurrence. They are hard tumors of varying 
size, with a roundish surface, sometimes smooth, and in 
other cases irregular. The base of such tumors runs into 
the surrounding bone, although it is usually quite well de- 
fined. They usually have a broad base, although some of 
them are pedunculated. The integument covering them is 
usually somewhat reddened, rarely very pale; and on touch- 
ing it with a probe, quite severe pain is usually caused. 
(I have, contrary to the experience of Professor Troltsch, 
never found those growths very sensitive. St. J. R.) 

They occur not only at the beginning of the osseous 
canal, but also close to the membrana tympani. They are 
almost always found on both sides, and several growths often 
proceed from different parts of the canal. I have several 
times observed such growths developed to such an extent, 
that the canal was almost obliterated. They occur much 

x 7 



13° EXOSTOSES TREATMENT. 

more frequently in men than women ; and they occur 
much less frequently as a result of painful inflammations 
than without any apparent cause. 

Toynbee considers these growths an evidence of a gouty 
or rheumatic diathesis. I have seen them as yet, chiefly 
in men who were good livers ; but I have never found 
any trace of arthritic deposits, and I have considered 
them as a co-incidental effect of catarrh of the cavity of 
the tympanum. 

The growth of these tumors usually advances very slowly. 
The syphilitic diathesis has usually no connection with 
their growth. These exostoses have been very frequently 
found in the skulls of natives of America. 1 

Treatment. — According to my experience, very little is 
to be expected from attempts to enlarge the canal by means 
of compressed sponge or lammaria digitata, or from the 
use of iodine locally and internally. It is very important 
to tell the patient to cleanse his ear very carefully with a 
syringe or camel's hair brush, since even small bits of epi- 
dermis, when thrown off, may tend to closure of the canal. 
Pedunculated exostoses may be readily broken off", but 
they do not usually lessen the caliber of the canal. When 
closure of the canal is induced by these growths, they may 
be removed by cutting, perforating, sawing and filing, and 
an improvement to the hearing expected. We should 
hope more from these operative removals, if post mortem 
section did not show that it is only exceptionally that they 
are hollow ; that is, that they are osseous vesicles, such as 
occur in the temporal bone, not only in animajs but also 
in men. 2 The most benefit will result from the im- 



i Welcker Archiv. fur Ohrenheilkunde, I, 3, S. 172. 

1 Autenrieth, Reil's Archiv. fur Physiologie, 1809, IX, p. 349, found such a growth to be 
cellular in its internal structure j and there was no connection of the air cells with those of 
the mastoid process. 



HYPEROSTOSES. I3I 

provement of the catarrh (purulent) of the cavity of the 
tympanum. 

Hyperostoses are attended with symptoms similar to 
those from exostoses. They not unfrequently occur in 
chronic otorrhoea, or remain after it. In this case we gene- 
rally find the walls of the canal contracted on all sides 
throughout its entire course. There are occasionally slight 
irregularities in the bony enlargement, while the exostosis, 
with its base well defined, owes its origin to an increased 
amount of local nutrition. The flat, undefinable hyperos- 
tosis is the result of a more decided inflammation of the 
periosteum, and belongs to the class of osleophytes. As 
a rule, the integument of the contracted auditory passage 
is more or less reddened. 

In cases where a secretion of pus is going on beyond the 
membrana tympani, such bony growths may prevent the 
exit of the discharge, and thus be an immediate cause of 
death. Dr. Roosa, 1 of New York, has reported an ex- 
tremely interesting case of this sort, where, in consequence 
of the retention of pus, meningitis was developed. 

(I have appended to the author's remarks on exostoses and hyper- 
ostoses the following cases ; the first being the one just alluded to. 
The cases, except the last, which has never before been published, 
were first reported in the New York Medical Journal, as above quoted 
from.) 

Case I. — Mr. C, aet. 39, was seen in April, 1864, in consultation 
with Dr. C. R. Agnew, under whose care he had been for some time. 
He had lost, before coming under observation, the hearing of his right 
ear, b"y inflammation and caries of the middle and internal ear. Pre- 
vious to the above date Dr. A. had removed a sequestrum, consisting 
of the cochlea and semi-circular canals, from the depths of the external 
auditory canal of the ear, and thus terminated the inflammatory action. 
In early life, Mr. C. had also suffered from "inflammation" of the 
left ear, producing the bony growths in the external auditory canal, 

1 New York Med. Journal, March, 1866 : Year Book of New Sydenham Society for 1866. 



I32 EXOSTOSES, CASES. 

which render his case the subject of present description. He now 
hears with his ear a watch tick at a distance of five inches. In the 
auditory canal, near the meatus, are two bony enlargements, which 
rise from the anterior and posterior walls, and project in a conical 
form, so as to occupy at least three-fifths of its caliber. These tu- 
mors have all the physical appearance of exostoses, and seem to have 
originated in periosteal inflammation. They have been steadily 
treated for many weeks by the local application of the saturated tinc- 
ture of iodine, and certainly not diminished in size. Pressure upon 
them excites pain, and induces an increase of swelling in the skin 
which covers them, and thus temporarily adds to the deafness. The 
entire absence of hearing in the fellow ear, and the failure of simple 
means to render the exostoses smaller, have suggested the propriety 
of some surgical operation for their removal. 

Such a proceeding has been thus far postponed by the occurrence 
of an acute attack of inflammation in the part, and extending to the 
tympanum, with symptoms of more than usual cerebral irritation. 
From this disagreeable complication he has entirely recovered, under 
Dr. Agnew's care. 

His general health being impaired he went abroad, and while in 
London consulted Mr. Toynbee, who used bougies, hoping to dilate 
the canal, but, according to Mr. C's statements, they caused much 
pain and accomplished nothing. Through Dr. Agnew's courtesy I 
again saw the patient in the spring of 1865, and found that the growths 
had so increased that only a small probe could be passed between 
them, and the hearing more impaired. The patient could still, 
however, hear the watch tick, but only when laid on the auricle. 

(The patient, whose case is here given, died of inflammation of 
the membranes of the brain, induced by suppuration in the cavity 
of the tympanum, the pus not being able to find an outlet, on account 
of the presence of the exostoses. Dr. Agnew exhibited the brain and 
temporal bones before the New York Pathological Society. m The 
history of the other ear of this unfortunate patient will be found in 
one of the subsequent lectures.) 

Case II. — A gentleman, aet. 40, whom I saw but once, in June, 
1864. He states that he had a "running" from his right ear for a 
number of years. For some two or three years past he had observed 
that the ear was stopped up. He was accustomed to remove the 
accumulating discharge by thrusting in a match armed with cotton. 



EXOSTOSES, CASES. I 33 

There is seen a bony growth arising from the posterior wall of the 
meatus, and involving the whole caliber of the canal, except a space 
large enough to admit an ordinary sized silver probe. Through this 
opening a slight amount of purulent discharge constantly makes its 
way. There was some hyperemia of the pharynx, and there was a 
small ulcer on one of the tonsils. The patient was in excellent 
general health, was rather a free liver, and said he had constitutional 
syphilis ; but no good evidence of its existence now existed. The 
patient had never had rheumatism or gout. 

Case III. — Mr. S., aet. 25, Conn., February 6, 1865 (a patient 
sent to me by Dr. Alfred North, of Waterbury). When the patient 
was three or four years of age he had scarlet fever, at which time his 
ears began to discharge ; and they have continued to do so at intervals 
ever since, with attacks of pain in the ears, which sometimes lasted 
for weeks, and prevented him from any occupation for the time. 
Eight years ago his ears were examined and polypi discovered ; one 
of which was removed by caustics. The attacks of pain have con- 
tinued to occur, the discharge continues, and his hearing is become 
more and more impaired. He is just now suffering from acute pain 
referred to the left ear. He hears the watch about one inch from 
each ear. 

In the right meatus there is seen a bony growth, reaching nearly 
out of the orifice of the external meatus, and arising from the posterior 
wall. The space between the growth and the anterior and upper wall 
is about large enough to admit of the introduction of a camel's hair 
brush. In the left meatus there is seen a gelatinous granulation, also 
reaching nearly out to the orifice of the meatus. 

On blowing air into the cavity of the tympanum, by means of the 
Eustachian catheter, air and fluid are heard making their exit into the 
external meatus ; but the blocking up of this passage prevents their 
emergence. On the right sight pus may be seen in the orifice between 
the bony growth and the wall of the meatus. 

The confinement of the fluid in the middle ear accounts for the 
pain in the left side, and the indication of treatment was to secure its 
free exit. This was done by removing the gelatinous growth by 
torsion, the patient being etherized, and rendering the Eustachian 
tubes permeable by the use of the well known means, — the catheter 
and Politzer's method. The granulation was found to have its origin 
, from a general bony expansion of the meatus. This growth had no 



134 EXOSTOSES, CASES. 

one point of attachment, but involved all the sides of the meatus, 
somewhat more expanded externally, giving the bony canal rather a 
funnel-shaped appearance. The bone was roughened. The pain in 
the ear disappeared as soon as these means for securing an outlet to 
the pus, constantly secreted from the cavity of the tympanum, and 
passing through the perforated membrana tympani, had been taken, 
and the hearing was so much improved that the watch was heard 
about four inches from the left auricle. He remained under treatment 
for a few days, and then returned to Waterbyry, and has been under 
the careful and able observation of Dr. North, who has applied reme- 
dies of various kinds to the left meatus, the patient keeping the Eusta- 
chian tubes permeable by means of gargles and Politzer's apparatus. 
The last time I saw the patient was in October of this year (1865), 
when the following note was made : " He has had no attack of pain 
in the ear since the first date. There is still a considerable discharge 
of pus from each ear. He hears ordinary conversation well, and the 
watch ten inches from his left ear, and two inches on the right ; a 
gain of one inch and nine inches respectively." The bony growth 
on the right side has not increased any, and that on the left is now 
smooth, and has a somewhat glistening appearance. June, 1868, 
patient still remains free from any disturbing symptoms. 

Case IV. — Woman, aet. 27, at the N. Y. Eye and Ear Infirmary. 
No reliable history could be obtained from the patient as to her ears, 
except that she had been occasionally hard of hearing for some years. 
She was quite sure that she never had had a discharge from the ears ; 
was in good general health, and had always been so. She could hear 
the watch two feet from the left auricle, and twelve inches from the 
right. The left membrana tympani showed evidences of previous 
inflammatory action, there being thickening of its mucous and fibrous 
layers. There is a bony enlargement of the posterior wall of the 
right meatus, so large as to prevent any view of the membrana tym- 
pani. The patient was seen but a few times, not continuing under 
treatment. 

Case V. — Mr. W., aet. 23, a patient sent to me by Prof. Fordyce 
Barker, of this city. Had scarlet fever when young ; and since that 
time has suffered from purulent discharge from the ear, and has been 
quite deaf. General health is excellent ; no gouty, rheumatic, or 
other diathesis. Hears ordinary conversation very near at hand with 



HISTORICAL. 



J 35 



very great difficulty. The watch is heard when pressed upon right 
meatus ; not at all on left. A gelatinous polypus was found attached 
to the hypertrophic posterior wall of the auditory canal. It was re- 
moved by torsion and nitric acid, applied to its roots. On left side 
there is a pedunculated, bony growth arising from the posterior 
wall, nearly occluding caliber of canal. Naso-pharyngeal catarrh. 
June, 1868, patient has been under observation since first date. 
Now hears conversation much better, watch at a distance varying 
from one to two inches, on right side. Secretion of pus, which, 
when patient was first seen was profuse, is now slight. Growths 
remain the same. 

Remarks. — As has been indicated in the respective histories, these 
growths were rather general enlargements of the periosteum, and of 
the bone structure immediately beneath, than tumors — true exostoses. 
Their nature seemed to be inflammatory, or, rather, hypertrophic. 
Perhaps all the similar growths recorded in the literature of aural 
surgery are of this character, i. e., morbid growths consequent on 
local irritation ; the irritating cause in these cases, with one excep- 
tion, Case IV, being clearly ascertained to be the contact of pus passing 
from the middle ear. The process in its inception was probably a 
periostitis, which may exist independently of an dyscrasia. Mr. 
Toynbee details nine cases in his well known work on the Diseases 
of the Ear, and remarks that " they seem to be the result of a rheu- 
matic or gouty diathesis." This certainly cannot be said of the cases 
here given ; and a careful examination of the histories of Mr. Toyn- 
bee's cases has caused considerable doubt to the present writer, as 
to whether they, too, were not rather to be ascribed to local inflam- 
matory action than to a diathesis. Virchow's views as to the etiology 
of bony growths in general may here be given : " With respect to 
the etiology of the hyperplastic osteomata, the fact cannot be lost 
sight of that local impressions were, in very many cases, the exciting 
cause. According to experience, entirely positive and generally very 
rude mechanical injuries form the ordinary starting point of the morbid 
process ; and, as has been already shown, this process presents itself 
substantially as an irritative one, often even as inflammatory, so that 
a boundary between bony products of inflammation and osteomata 
cannot generally be drawn." 1 

1 Die Krankhaften Geschwulste, II Band., I Halfte, p. 73, et seq., passim. 



I36 EXOSTOSES, ETIOLOGY. 

" Some have, indeed, educed the frequent cases where certain con- 
stitutional diseases, especially rheumatism, arthritis, syphilis, scorbutus, 
rachites, have produced bony tumors, as being something opposed to 
these local causes. Undoubtedly the field of these conditions was 
formerly too widely extended ; and we may say that scorbutus is now 
almost entirely excluded from the list of causes, and that the gouty 
enlargements of bone are no growths (gewachse), but only deposits 
(ablagerungen). But we may not deny the influence of the other so 
called dyscrasia, especially of the rheumatic, syphilitic, and rachitic 
conditions. In spite of this, the influence must not be over esti- 
mated," etc. 

"As to rheumatism and syphilis, we may not here even content 
ourselves with assigning constitutional causes ; for the affection of one 
single bone must always be considered as dependent on a local im- 
pression." 

As also interesting in considering this subject of bony growths, 
parts of an article by Professor Welcker, of Halle, referred to by 
the author, are here reproduced : J 

" Professor Seligmann has made the interesting statement that, in 
the various American skulls found in different collections, skulls 
known as Titicaians, Huankas, Aymaras, and which have been elon- 
gated by pressure during infancy, exostoses in the external auditory 
canal are very common. He says, of six skulls which I have, up to 
this time, examined, five have such exostoses. In the very similarly 
deformed so called Avarian skulls, exostoses did not exist. This is 
certainly a remarkable phenomenon, and may well justify the inquiry ; 
are these exostoses a peculiarity of race, or are they a certain produc- 
tion of an injurious cause, especially efficacious in this race ? My 
honored friend, Professor Seligmann, has promised us a closer examina- 
tion as to this. Still, I do not think that he will be able to maintain 
his present opinion, which is, that this abnormity is found only in the 
class of skulls above named. My memorandum of the examination 
of a North American Fox Indian, No. 229 of the Heidelberg collec- 
tion, reads, c exostoses in the auditory canal.' Of nine skulls of 
Marquesan Islanders, which neither belong to the American race nor 
exhibit a trace of artificial deformity, I found aural exostoses in two, 
one of which was in an advanced stage of development. To this 
must be added, that in the civilized nations of Europe these exostoses 

i Archiv. fur Ohrenheilkunde, I Band., Ill Halfte, 1864. 






EXOSTOSES, ETIOLOGY. I 37 

are by no means as seldom as the writers on aural surgery indicate ; 
and I believe, after thoroughly reviewing the collection described by 
C. O. Weber (Die Exostosen und Enchondrome, Bonn, 1856), that 
the meatus auditorius externus may be designated as a peculiarly 
favorite position for these growths. The appearance of these exos- 
toses, as one of the well known consequences of disease, is by no 
means the view of Professor S. ; but he regards them as peculiar to 
the Titicaian skulls. But I do not agree with him in thinking that 
the exostoses of that foreign race should be considered as anything 
different from the same familiar condition appearing on the German 
skull, and recognized by aural surgeons. We are, however, indebted 
to the studies of Professor Seligmann for the knowledge of the cer- 
tainly not uninteresting fact, that these exostoses occur much more 
frequently in the transatlantic skulls "than in those of the population 
of our own continent. Thus, in the examination of the skulls of 
foreign races, I have found the three before named cases of aural 
exostoses, while in the Caucasian skulls, which I have examined in 
a much larger number, I have not as yet met with a single one. 
St. J. R.) 



18 



LECTURE X. 

INFLAMMATION AND INJURIES OF THE MEMBRANA TYMPANI. 

Affections of the membrana tympani very common, but seldom 
occurring alone and uncomplicated ; acute and chronic myrin- 
gitis ; bad effect of cold upon the ear; lacerations and per- 
forations of the membrana tympani ; several cases of fracture 
of the handle of the malleus. 

Gentlemen : Affections of the membrana tympani occur 
very frequently. This we would infer from its position 
and anatomical construction. It forms the partition wall 
between the auditory canal and cavity of the tympanum. 
It can, therefore, be considered as belonging to both parts ; 
and it takes part in the affections of each of them. More- 
over, tissue from either side is extended upon its surface ; 
on the outer side from the auditory canal, a covering of 
skin and epidermis, and on the inner a continuation of the 
mucous membrane of the cavity of the tympanum, or 
middle ear. All the vessels and nerves of the membrane 
are found in these two layers, while the middle fibrous 
layer has neither. It is thus evident that the membrane 
will almost always participate in the affections of the ad- 
joining parts. We should also remember that three of 
the most important tissues of the animal system are found 
in this membrane, integument, mucous membrane, and 
fibrous tissue. Hence pathological changes are very com- 
mon in the part. 

Although affections of the membrana tympani are very 



I 



AFFECTIONS OF MEMBRANA TYMPANI. I 39 

frequent, exact and unprejudiced observation must show 
that they seldom occur alone, and uncomplicated with an 
affection of another part of the ear. The membrana tym- 
pani is nourished by the same blood vessels and nerves 
that supply the cavity of the tympanum and the auditory 
canal. It thus really only forms a part of these divisions 
of the ear. In any affection of the adjacent parts therefore, 
the drum will almost always be involved, while its inde- 
pendent affections must react upon these adjacent parts, if 
the morbid process be severe. 

This extension to the other parts will be more apt to 
occur if the affection is attended by suppuration, the pus 
acting as an irritant upon these structures on account of the 
smallness of the space involved. Since this reciprocal rela- 
tion between the membrana tympani and its adjacent parts 
exists in acute affections, we are much less able, in the very 
chronic suppurative processes, to determine whether it was 
an inflammation of the auditory canal or of the cavity of 
the tympanum, which first existed and subsequently in- 
volved the membrana tympani. 

This view, that genuine and uncomplicated inflamma- 
tions of the membrana tympani are comparatively rare, is 
contrary to the one commonly accepted, and to the teach- 
ings of writers on aural medicine and surgery. I am con- 
strained to this opinion, however, from observation on a 
considerable number of patients, made, so far as I am able, 
in an impartial manner. The anatomy of the parts in- 
volved, as well as the history of the cases in the text books, 
described under the head of inflammation of the membrana 
tympani, when they are carefully examined, also sustain 
this view. If we read these critically, we see that the 
symptoms and the objective appearances of the acute 
inflammation of the membrana tympani are generally those 
of a diffuse inflammation of the auditory canal, or of an 
acute or purulent catarrh of the cavity of the tympanum, in 



I40 MYRINGITIS OBJECTIVE SYMPTOMS. 

either of which processes, it is easy to see that the drum 
of the ear will readily enough be involved. We can by no 
means believe, from the descriptions, that the membrana 
tympani was usually first, and attacked independently. 
Just so we should call the chronic inflammation of the 
membrana tympani of various authors chronic catarrh 
of the cavity of the tympanum, with consecutive changes 
and inflammation of the membrana tympani. 

Myringitis 1 may occur in an acute and chronic form. 
The cases which I have observed in the acute form always 
occurred suddenly and in the night, generally after exposure 
to cold ; often after cold bathing. They were accompa- 
nied by severe pain, which increased in placing the affected 
ear on the pillow. There is a feeling of fullness, insensi- 
bility, and heaviness, and almost always a very great noise 
in the ear. These symptoms, with unfrequent interrup- 
tions, last from twelve hours tp three days, and cease so 
soon as the auditory canal becomes moist, and a gradually 
developed discharge from the ear begins. In one case the 
pain ceased after a sudden attack of haemorrhage from the 
ear, which, according to the patient's account, was to the 
extent of a table spoonful of blood. 

Objective Symptoms. — In the beginning, hyperemia of 
the membrana tympani is seen. It appears as if it were 
artificially injected. There are not only some large vessels 
running along the handle of the malleus from above down- 
wards, to the central and most concave portion of the 
membrana tympani, called the umbo, and radiating from 
this point, but there are also vessels on the periphery, 
running to the center, and connected on all sides with 
vessels of the canal. As a consequence of the infiltration 
of the epidermis, the shining appearance of the membrana 

1 So named by Linke and Wilde. 



MYRINGITIS^ OBJECTIVE SYMPTOMS. 141 

tympani is soon lost, and its external surface becomes dull, 
like glass that has been breathed upon. 

The handle of the malleus, which, in a normal condi- 
tion, may be seen as a yellowish white stripe, in the middle 
of the membrana tympani, is not to be seen, while, at the 
same time, the membrane appears somewhat flattened. In 
the later stages the epidermis is lifted up in little lumps or 
lamellae; and the corium, or true skin, is red, swollen, 
relaxed, and covered with a thin secretion. The auditory 
canal, which, in the beginning of the attack, remains en- 
tirely unaffected, becomes injected very quickly in the 
neighborhood of the drum, so that the usually well defined 
boundary between the two parts is obscured. In some 
cases of this nature which I observed, the process went on 
to ulceration and perforation of the membrana tympani. 
In one case a kind of sub-cutaneous ecchymosis occurred. 
In another I observed on the posterior and upper edge of 
the membrana tympani a swelling about as large as a pea, 
yellow, soft, and tender, touching which with a probe 
caused severe pain. This little elevation in the membrana 
tympani, protruding its surface into the auditory passage, 
I regarded as an abscess formed between its layers. 1 It 
decreased gradually with the subsidence of the inflammatory 
process. 

Under favorable circumstances, the generally slight 
amount of discharge from the ear gradually ceases, the 
redness and infiltration disappear, and the membrane is 
again covered with epidermis. It always, however, remains 
for some time dull and flat in appearance. The handle of 
the malleus, so distinctly to be seen in a normal condition, 
is not now so plain, in consequence of the thickness of 
the layer of cutis. We are therefore able to recognize an 

1 Wilde observed such small circumscribed depositions of pus between the layers of the 
membrana tympani in ten cases. These interlammellar abscesses are not very rare, according 
to recent observations. 



142 MYRINGITIS CAUSES. 

infiltration into the membrane long after its occurrence. 
So far as I have observed, these cases are apt to occur in 
one ear alone. 

Since acute inflammations of the auditory canal and of 
the membrana tympani occur particularly often after cold 
bathing, every one should protect the ear while in the 
water by some sort of covering, or by a bit of cotton in 
the meatus. These precautionary measures are doubly 
necessary when the water employed is cold, or in sea 
bathing, where the force of the waves and the salty con- 
stituents come into consideration. 

Besides this precaution, all fluids that are dropped or 
syringed into the ear should be previously warmed, lest 
their use produce an unpleasant or even injurious effect. 
Cold injections of the ear may easily cause vertigo and 
fainting, while filling the ear with warm water generally 
causes an extremely pleasant sensation, and is one of the 
most efficacious remedies for pain in the part. It is also 
very necessary to carefully stop the ear of the patient 
when iced applications are made upon the head ; since the 
dropping of cold water into the ear not unfrequently adds 
a second and very painful affection to the original disease. 
An inflammation of the ear, arising in this way, might 
easily give a false idea as to the nature of the disease, since 
it would certainly be the last thing believed, that the sud- 
denly occurring aural affection depended upon the water 
that had entered the ear. 

Wreden x has observed several cases of inflammation of 
the membrana tympana caused by the growth of fungi, 
asperquillus glaucus. He calls the affection myringomykosis, 
or myringitis parasitica. Recent observations show that 
such fungoid deposits upon the outer surface of the drum 
are not rare. 

» Archiv. fiir Ohrenheilkunde, III, B. I. 



•I 



CHRONIC MYRINGITIS. I43 

Chronic Myringitis. — This is more common than the 
acute form. It is less severe, however, than other affec- 
tions, and there is a very slight amount of suppuration, 
since severe inflammations of this kind either involve the 
auditory canal, so that the affection resembles a chronic 
otitis externa, or they extend to the middle ear through 
an ulceration and perforation of the membrana tympani ; 
and then, of course, we are dealing with a chronic otitis 
interna. 

Simple, uncomplicated, chronic inflammation of the mem- 
brana tympani, as a rule, occurs with such slight subjective 
symptoms, that the attention of the patient is first called 
to the affection by some slight discharge from the ear, or 
moisture on the pillow. An annoying itching sensation 
in the ear is occasionally complained of; but the pain is 
usually so slight and evanescent, perhaps after some sort 
of injury to the ear, and the affection disturbs the patient 
so little, especially if one ear alone be involved, that it often 
exists for years before medical advice is sought. 

Objective Symptoms. — On examination of the external 
auditory passage, we find no changes, except a partial 
softening of the epithelial covering in the immediate neigh- 
borhood of the membrana tympani, in consequence of its 
contact with the secretion. The secretion is generally 
small in quantity, quite consistent, with an offensive smell. 
It covers the membrana tympani, and always appears on 
the adjacent parts in the form of crusts. The drum, even 
when there is no secretion from it, always appears dull and 
hazy, so that we can only just make out the handle of the 
malleus, and its short process. The epidermis — but only 
in certain points, generally posteriorly and above — is re- 
moved ; and these points are red and swollen- The mem- 
brane appears variously yellow or grey in color, thick- 
ened, with varicose vessels running over it, which are gene- 



144 MYRINGITIS PROGNOSIS. 

rally found on the periphery. Not unfrequently we find a 
partial sinking inwards of the membrane, with irregularities 
in its curvature and plane. These indicate adhesions with 
portions of the cavity of the tympanum. Partial calcare- 
ous and exudative depositions are also not a rare result of 
inflammations of the membrana tympani. Polypi may be 
developed from the small swellings, spoken of above, 
and the purulent discharge is often kept up by these 
alone. 

Prognosis. — In the acute form this is very good, if the 
patient be properly treated. The purulent discharge soon 
ceases, and the pain does not return. Recent perforations 
heal quite readily, when there is no purulent catarrh of 
the middle ear connected with it. The thickening of the 
membrane also gradually disappears, and the hearing is 
restored. Under favorable circumstances scarcely a vestige 
of the disease remains. On the other hand, if the disease 
be neglected, if it be treated with poultices, or with irri- 
tating ear drops, the membrana tympani will remain per- 
forated, and the otorrhoea may easily become chronic. The 
purulent inflammation will extend itself more and more 
on all the other parts, and all the consequences of a chronic 
otitis may develop themselves from a simple myringitis. 
We shall see further on, in the course of these lectures, 
what an importance chronic otitis has, for health and life. 

In chronic myringitis the prognosis is much less favor- 
able ; for it is only by treatments, continued for years 
perhaps, that we are able to restrain the secretion, and even 
then there will exist a certain tendency to relapse. Fur- 
thermore, the pathological changes, especially the thick- 
ening of the membrana tympani, are generally so great, 
as not to lead us to expect much of an improvement in 
the hearing. In individual cases, however, great patience 
in the treatment produces very good results. 






MYRINGITIS TREATMENT. 1 45 

Treatment. — There is very little to say here, since the 
treatment is very like that of otitis externa. In acute 
myringitis, in order to guard against the danger of perfora- 
tion of the membrana tympani, in connection with local 
blood-letting, you will give cathartic doses of calomel 
with jalap. (It may be considered extremely probable that 
a mild cathartic will do better than the one here sug- 
gested. St. J. R.) Poultices should not be employed ; 
but warm water may be slowly and carefully poured into 
the ear, according as there is pain felt in the part. Since 
we have learned from experience that perforation of the 
membrana tympani is particularly apt to occur during 
vigorous expiratory efforts, we should always warn the 
patient not to blow his nose very vigorously, and to avoid 
all agents which may cause sneezing. 

Very recently, Schwartze* has urgently recommended 
" paracentesis of the membrana tympani," in certain cases 
of acute inflammation of the membrana tympani, where a 
very great swelling appeared in the usually dark bluish red 
tissue. This swelling is greatest at the posterior and upper 
quadrant of the membrana tympani ; and the pain in the 
ear is not usually relieved by other remedies. 

Paracentesis acts in these cases by relaxing the tissue, 
and perhaps by direct depletion of the vessels of the mem- 
brana tympani. It relieves the pain and materially shortens 
the process, as repeated observations show. The opening 
very soon closes again, and ulceration of the drum never 
occurs. (This little operation is nothing more than eva- 
cuating an abscess, and. is certainly indicated in the acute 
cases, where very considerable bulging outwards of the 
membrana tympani is observed. With the present means 
of examination, it is not at all difficult to accurately deter- 
mine the existence and situation of any such swelling. St. 

J- R-) 

i Archiv. fur Ohrenheilkunde, B. II, S. 266. 

J 9 



146 MYRINGITIS TREATMENT. 

If exudation has occurred, you should daily cleanse the 
ear by careful syringing, and afterwards drop in a mild 
astringent. In cases of long duration of the treatment, 
when the discharge becomes chronic, the remedies should 
be often varied. Under this treatment the purulent dis- 
charge will cease, and a quite extensive perforation will 
heal. For the remaining thickening of the membrana 
tympani, tincture of iodine, or an iodurated salve should be 
rubbed behind the ear. If there is no purulent discharge 
present, and there has been none for some time, we may 
employ irritating agents with which to pencil the drum, as 
well as irritating drops in the ear. I have sometimes seen 
good results in superficial thickening of the membrana 
tympani from strong solutions of the bi-chloride of mer- 
cury, from one to four grains to the ounce. The pain of such 
an application is sometimes very severe, and we must be 
very careful that none of the fluid be collected together on 
the anterior and lower portion of the membrana tympani, 
where it would readily perforate it ; and you must never 
undertake such a treatment when you cannot have the 
patient under your eye. 

Any portions which may be particularly swelled may be 
pencilled with strong solutions of sulphate of zinc, with 
tincture ferri sesquichlorati, or with dilute or concentrated 
acetic acid. 

In the use of the latter named agent we should carefully 
remove all metallic depositions, in order that their adher- 
ence to the drum may not cause an irregular vibration. 
In some cases such granulations should be cauterized with 
a pointed bit of nitrate of silver, or removed by Wilde's 
polypus snare, of whose use we shall learn at a later period. 

Injuries of the Membrana Tympani. — We may for the 

present omit any consideration of the secondary changes 
in the membrana tympani, resulting from diseases of the 



INJURIES OF MEMBRANA TYMPANI. 147 

cavity of the tympanum and pass on to a consideration of 
the injuries of the membrane. These are quite common, 
as we would infer from the delicacy of structure of the 
membrane, and its exposed position. Ruptures of the 
membrane are the injuries that usually occur. They result 
from too strong a pressure of air acting upon the drum from 
without, whether in consequence of a box on the ear, etc., 
or from explosions occurring near the ear. I have seen 
old and recent ruptures of the membrana tympani, the 
latter often accompanied by otorrhcea, which were owing 
to a box on the ear received at school. A short time ago 
a student presented himself to me, who had received a slap 
on the ear in a joke, and since which he had felt a slight 
pain in the ear. No discharge had occurred. The mem- 
brana tympani showed a rupture parallel with the handle 
of the malleus, running its whole length. The edges of 
the wound were reddened, and covered with blood. The 
posterior half was greatly injected, the anterior normal, and 
the hearing was considerably diminished. 

The attention of parents and teachers should be earnestly 
called to the fact, that the vicinity of the ear is a very inap- 
propriate part for the application of corporeal punishment. 
They should be told how easily a rupture or inflammation 
of the drum may be caused by a blow upon the auricle. 
Ruptures of the membrana tympani may also occur from 
striking the head upon the water when bathing. 

It has been denied, but improperly, that rupture of the 
membrana tympani may occur from the explosion of can- 
non. I have seen one recent case, and several old ones, 
which, without doubt, were thus caused, where linear per- 
forations or cicatrices were to be seen. The course of these 
is almost always posterior to, and parallel with the handle 
of the malleus. Such cicatrices appear as greyish white, 
sometimes slightly bronzed lines. Very many cases of 
deafness occur among artillerists who have served a very 



148 INJURIES OF MEMBRANA TYMPANI. 

long time ; and they always date it, to a moment, when 
standing near a cannon in the act of discharging, they felt 
a heavy blow and pain in the ear turned towards the cannon. 
Blood is said to usually escape. In some cases I found 
the impairment of hearing so great, as to imply that still 
more serious injuries had taken place. 

When the affection is only on one side, an examination 
with the tuning fork will decide whether any more than 
the peripheral parts of the organ have suffered harm. 

We may guard against injury to the membrana tympani 
when great concussions of the atmosphere are taking place, 
by stopping up the ears, drawing the shoulder up against 
the ear most in danger, and particularly by practicing the 
method of inflating the middle ear, known as Valsalva's. 
This method consists in making a powerful expiration, 
with the mouth and nostrils closed. These methods are 
certainly more reliable than the one traditionally employed 
among artillerists, i. e., merely opening the mouth. The 
tension on the pharyngeal mucous membrane that is pro- 
duced in drawing back the jaw, can certainly open the 
pharyngeal orifice of the Eustachian tube but very little. 

It is evident from the nature of things, that every 
sudden condensation of the external air must act more 
powerfully if the tube be impermeable upon a membrana 
tympani whose excursive power is impaired, and also upon 
the deeper parts, the contents of the cavity of the tympanum 
and of the labyrinth, than when the air in the cavity of the 
tympanum can make its way out through the Eustachian 
tube. 

In a great number of cases, which I have examined soon 
after such an accident as rupture of the drum has occurred, 
there has been severe pharyngeal catarrh with impermea- 
bility of the affected tube. 

(I once saw a case where rupture of the drum was caused 
from the explosion of a pistol in the immediate vicinity of 



INJURIES OF MEMBRANA TYMPANI. I49 

the patient's ear. She was unaware that the pistol was 
about to be fired. It will be observed that comparatively 
few ruptures occur where the explosion is expected, al- 
though singing in the ears is always produced. It is a 
remarkable fact that comparatively few cases of rupture of 
the drum occurring during the great artillery duels of our 
late civil war, have come under the observation of surgeons, 
or at least that very few have been reported. I have seen a 
few cases of deafness resulting from concussion of the 
contents of the labyrinth, from the firing of artillery, espe- 
cially when soldiers in the front rank lay down while 
cannon were fired immediately over their heads. St. J. R.) 

It is well known that the membrana tympani is often 
ruptured in the case of fracture of the skull. Rupture 
also occurs in whooping cough, with or without hemor- 
rhage from the ears. Wilde relates two cases where it 
occurred after suicidal hanging. But this is not always 
the case when death occurs by hanging, as was shown by 
one case that I examined, where no such injury oc- 
curred. 

Perforation of the membrana tympani is sometimes 
caused by the introduction of sharp objects, in order to 
relieve itching sensations in the part. Women not unfre- 
quently use their knitting needles for this purpose. I 
have seen several cases of perforation of the membrana 
tympani thus induced. 

Careless probing the ear, on the part of an examining 
surgeon, may also produce perforation of the membrana 
tympani. You should never introduce a probe any fur- 
ther into the ear than you can see at the same time, so 
that the eye may guide the hand. The disregardance of 
this precaution has caused much harm to result from the 
probing the ear. It is sometimes practised in order to de- 
termine the existence of caries, or of a perforation, and then 
has itself caused the latter. In the greater number of cases 



I50 INJURIES OF MEMBRANA TYMPANI. 

in which the probe is still used, the eye, i. e., with a proper 
examination and good illumination, furnishes much more 
exact conclusions as to the condition of the parts than the 
sensation communicated to the fingers through the probe. 
(I have observed two cases where the membrana tympani 
was ruptured by the examining physician, who attempted 
to learn if the impaired hearing was caused by hardened 
wax. St. J. R.) I once observed a case of perforation of 
the membrana tympani from a blade of straw. It occurred 
to a school teacher in the country, whom I often saw on 
account of another affection of the ear. As this man was 
going up into his hay loft on a ladder he hit his head against 
a bundle of straw, and one of the blades entered his ear. 
This caused such fearful pain that he almost fainted, and 
he could scarcely keep himself on the ladder. He suffered 
for about half a day from severe pain in the ear, which 
then left him. 

The impairment of hearing already existing was not 
increased by this accident ; and he thought that the sissing 
sound. in the ear, which had troubled him for years, had 
become somewhat less since then. About two weeks after 
I found a small black triangular spot in the posterior and 
lower part of the membrana tympani, which resembled a 
perforation closed by coagulated blood. I saw a similar 
case in a farmer, who got a blade of straw in his ear, while 
he was unloading the bundle from a wagon. He fainted 
from the effect of the injury. 

Treatment. — Especial treatment will scarcely be necessary 
in recent and simple cases of this kind. The drum readily 
heals ; its regenerative power being very large. Magnus 1 re- 
lates a case where a gardener got a twig of birch into his ear, 
which was not removed until three days later. The mem- 
brana tympani was extensively torn, and a severe suppura- 



1 Magnus, Archiv. fur Ohrenheilkunde, I, B. I, S. 43. 






FRACTURE OF HANDLE OF THE MALLEUS. 151 

tive inflammation had occurred. In spite of this, in three 
weeks the hearing power and membrana tympani were 
normal. It was only on the employment of the Valsal- 
vian experiment that the bulging forward of a portion of 
the drum showed where the rupture had occurred. After 
injuries of this kind, we should close the ear lightly with 
cotton, and guard it from all injurious influences. 

Cases of concussion from explosions, such as occur to 
artillerists, where severe injuries, hemorrhages, and lacera- 
tions of the deeper parts have resulted, demand of course 
careful observation, and treatment according to general 
therapeutic principles. We shall speak of this subject 
again when we come to the subject of nervous deafness. 

Fracture of the Handle of the Malleus. — To this place 
belong the few cases which have been observed of fracture 
of the handle of the malleus. Meniere 1 speaks of such a 
case occurring in a gardener, who accidentally had a twig 
of a pear tree thrust in his ear. A very extensive lacera- 
tion of the membrana tympani took place, and the little 
bones of the ear could be plainly seen, and their movements 
distinguished. This remarkable injury healed of itself, 
without any especial treatment. I myself saw a case of 
united fracture of the handle of the malleus. A wine 
merchant thrust a pen handle, which he held in his hand, 
into his ear, in consequence of knocking his elbow against 
an open door. The severe pain caused him to faint, and 
he did not recover for some minutes. Cold water was 
immediately put in the ear, and he could not tell whether 
blood flowed from it or not. After that time he heard 
poorly from the injured ear, and suffered from noises in 
it, more especially if he lay on that side. When I saw the 
case, one year later, the peculiar slanting position of the 
handle of the malleus was very striking ; it also appeared 

* Gazette Medicale de Paris, 1856, No. 50. 



I52 FRACTURE OF HANDLE OF THE MALLEUS. 

uncommonly thick and prominent at a point immediately 
under the processus brevis, and from this point out turned, 
as it were, on its axis. In short, it resembled a case of 
united fracture of the handle of the malleus. Hyrtl 1 de- 
scribed such a united fracture, which he found in the ear 
of a prairie dog (Arctomys ludovicianus), which had a very 
similar appearance; and was, also, as in the above case, 
immediately under the neck of the malleus. He states 
that such an injury is not remarkable as occurring in this 
animal, since it is a relative to our marmot (mole), lives 
in caves or holes under the ground, and has a membrana 
tympani that is very superficially situated, in consequence 
of the shortness of the auditory canal. 2 (Professor Joseph 
Hyrtl, teacher of anatomy in the Vienna University, has 
a very extensive collection of the little bones of hearing, 
and of the internal ear of the mammalia. 

(My friend, Dr. R. F. Weir, surgeon to the New York 
Eye and Ear Infirmary, has kindly furnished me with the 
notes of a case of ununited fracture of the handle of the 
malleus, that came under his observation at that Institu- 
tion. The patient was an Irish laborer. Four months 
before he was seen by Dr. Weir he received a fall, of 15 
feet, which caused unconsciousness and bleeding from the 
ear. He had pain in his ear for 16 hours after, running 
along the forehead to the ear. Was laid up for a month, 
and then pain passed away. The tinnitus aurium is very 
great. On examining the right ear, the handle of the 
malleus seems to have been fractured just below the short 
process, where an irregularity is seen, and the lower frag- 
ment moves with great freedom upon the upper. The 
irregularity disappears after inflating the ear by the Val- 
salvian method. On the posterior part of the drum a patch 

1 Wiener Medicinischer Wochenschrift, No. ii, 1862. 

2 Toynbec only mentions such a case of fracture without a history. Catalogue of Prepara- 
tion Illustrative of Diseases of the Ear: London, p. 68. 



FRACTURE OF HANDLE OF THE MALLEUS. I 53 

of increased whiteness is seen, and possibly it indicates the 
site of a rupture. In ten or fifteen minutes afterwards 
the displacement of the bone again occurs." St. J. R.) 



20 



LECTURE XI. 

ANATOMY OF THE MIDDLE EAR. 

The cavity of the tympanum ; general view ; outer wall, or 
membrana tympani ; floor y or wall of the jugular fossa ; roof 
or wall of the membranes of the brain ; {fisssura petro-squa- 
mosa;) inner wall, or wall of the labyrinth ; (fenestra ovalis 
and rotunda ; promontory ; carotid artery and venous sinus ; 
the relations of the facial nerve to the cavity of the tym- 
panum ; muscles of the cavity; projection inward of one of the 
semi-circular canals;) posterior wall, or wall of the mastoid 
process ; opening of the Eustachian tube into the cavity of the 
tympanum ; topographical view ; the different diameters of 
the cavity of the tympanum ; its mucous membrane in the 
adult and the foetus. 

Gentlemen : Now that we have considered the diseases 
of the external ear, we turn to those of the middle part of 
the organ of hearing. We may at first more exactly study 
the place in which these affections are developed, and run 
their course ; and this leads us to a study of the anatomy 
of the middle ear. 

The most important part of this division of the auditory 
apparatus is the cavity of the tympanum ; a space between 
the membrana tympani and the labyrinth, filled with air, 
in which are found the three ossicula auditus, forming an 
articulated and variously tense connecting chain between 
the outer and inner ear. 

On practical grounds, we must consider as especially 
important, the relations of this cavity to the brain and its 



THE CAVITY OF THE TYMPANUM. 1 55 

membranes, to the internal carotid artery, internal jugular 
vein, and finally to the facial nerve. There are also to be 
mentioned the two muscles of these ossicula, and the 
openings, or fenestra^ leading to the labyrinth. 

Since it can be demonstrated that the greater number of 
pathological changes occurring in the ear are localized in 
the cavity of the tympanum, it is very important for the 
physician, that he have more than a general idea of the 
anatomy of this cavity, and of its relations to the adja- 
cent structures, that have just been mentioned. The 
apparent difficulty of the subject lies in the facts, that the 
cavity is very small, the noteworthy points very many, and 
that we seldom have an opportunity of an actual view of 
the parts. 

It will be best for us to notice only the most important 
of these parts, describing the different walls in their order. 
An indication of these at this juncture may perhaps facili- 
tate our understanding of the subject. 

The cavity of the tympanum may represent an irregular 
space, having six sides : 

I. Outer wall, or membrana tympani. 
II. Inner wall, or wall of the labyrinth. 

III. Upper wall, or roof; the wall of the cerebral mem- 

branes. 

IV. Lower wall, or floor; wall of the jugular vein. 

V. Wall of the mastoid cells, passing anteriorly into the 
VI. Eustachian tube. 

We have already studied the outer wall, or side, or mem- 
brana tympani, it being chiefly formed of this membrane, 
with the two ossicula auditus, — the malleus whose handle is 
inserted in its layers, and the incus articulating with the 
latter. The long process of the incus lies parallel to the 
handle of the malleus, and behind it, but does not extend 
so far down. 



I56 THE CAVITY OF THE TYMPANUM. 

In the foetus and the newly born, we find a vascular fold of mucous 
membrane extending the whole length between the process of the 
incus and the handle of the malleus. When this connection of these 
two parts is found in adults, it must be considered as pathological. 
It is, however, possible that this foetal condition does not always dis- 
appear completely or at all. 

By removing the incus, we get a view of the whole of 
the posterior pocket or pouch of the membrana tympani. 
On the malleus, under the neck, we observe the insertion 
of the tendon of the tensor tympani muscle, and immedi- 
ately above it the chorda tympani of the facial nerve, 
running under the long process of the incus, on the free 
margin of the posterior pocket of the membrana tympani. 
It crosses the neck of the malleus, and then, after assisting 
to form the anterior pocket, leaves the ear through the 
Glaserian fissure. 

The most important part of the tendon of the tensor tympani, that 
is, the actually tendinous portion, is inserted close under the chorda 
tympani. A more delicate portion curves upwards and anteriorly 
along the free border of the anterior pocket. The muscle itself is 
surrounded by quite a thick envelope of connective tissue, in its osse- 
ous canal, which accompanies it like a sheath obliquely across the 
cavity of the tympanum. If we draw upon the muscle, besides the 
membrana tympani itself, chiefly its middle portion, the tendinous 
cord, extending over the cavity of the tympanum, also moves. A 
transverse section of this tendinous cord, even with slight magnifying 
power, shows that the thicker central tendinous mass is surrounded 
by a looser connective tisue, and that the two component parts are 
demarcated from each other by a distinct circular line. 

The Glaserian fissure, lying close to the anterior border 
of the membrana tympani (called fissura petro tympanica by 
Henle), is one of those commissures which recalls the fact, 
that the temporal bone, in foetal life, is made up of several 
independent bones. In a child, where a fissure-like gap, 
filled up by soft parts, still exists, this passage might 



THE CAVITY OF THE TYMPANUM. 1 57 

afford a way for the transition of an aural affection upon 
the articulation of the jaw. 

An Italian anatomist, Dr. Vergaf very recently described a ligament 
that passes from the malleus obliquely upwards, and is inserted upon 
the inferior maxillary bone, as the malleo-maxillary ligament. In the 
human subject this is only easily recognized during the last five months 
of intra uterine life ; and it is said to be a transition form of Meckel's 
cartilage. Even after birth, it does not always completely disappear, 
but gradually two distinct and well known parts are formed from it: 
From the part belonging to the cavity of the tympanum is formed the 
so called anterior muscle of the malleus, which in reality is a ligament. 
The remaining portion becomes thickened where it is attached to the 
lower jaw, and thus becomes the internal lateral ligament of the infe- 
rior maxilla. 

It is important to observe what has already been alluded 
to, that the cellular cavities of the temporal bone are some- 
times very large above and behind the head of the malleus, 
and thus extend for a distance beyond the membrana tym- 
pani into the bony tissue, which makes up the upper wall 
of the osseous auditory canal, and are connected (see figs. 
i and 2) to the cells of the mastoid process, which, as is 
well known, form the posterior wall of the osseous meatus. 

Thus a way is made by which affections of the middle 
ear, and especially suppuration, not involving the mem- 
brana tympani, may extend externally and, breaking through 
the upper wall of the meatus, evacuate themselves in this 
part of the ear. Such secondary depositions of pus, under 
the integument of the upper part or roof of the meatus 
are not very rare. Deep abscesses of the ear may be some- 
times evacuated externally by making an opening at this 
point. 

The temporal bones of different individuals are so very 
different that no one pair can be found exactly like another. 

1 Journal de Med., Chir. et Pharm : Bruxelles, 1854, p. 417. Archiv. fur Ohrenheil- 
kunde, II, S. 230. 



I58 THE CAVITY OF THE TYMPANUM. 

The difference in structure is markedly seen on the lower 
wall, or floor, of the cavity of the tympanum. It is some- 
times several lines in thickness, with long ridges and cel- 
lular depressions, composed in part of dense spongy, bony 
substance. Again, it is so thin as to be translucent ; in 
which condition the internal jugular vein lies immediately 
under it. 

This very frequent close contiguity of the jugular 
vein to the cavity of the tympanum highly deserves the 
attention of the practitioner as well as the anatomist. Ac- 
cording to simple, physical laws, no portion of the cavity 
of the tympanum is so exposed to the influences of pus 
collected in it as the floor. A stagnation and deliquescence 
of the secretion collected here can the more readily occur, 
because the two openings by which it might be removed, 
— the point of entrance of the Eustachian tube and the 
opening into the mastoid cells, — lie somewhat higher. 

Pus that becomes decomposed will necessarily irritate 
and macerate the mucous membrane, and subsequently the 
bone lying under, and thus cause inflammatory softening, 
and finally ulceration in this part. Caries of bone in the 
vicinity of a vein, such as the internal jugular, cannot be 
an indifferent matter, especially since the intervening osse- 
ous layer is very thin, and perforated by a delicate canal 
for the tympanic nerve (of the glosso-pharyngeus), and for 
a minute vessel. 

Still more, without any previous disease, there may be 
fissures in the floor of the cavity of the tympanum. 1 In 
many animals the lower wall is always covered by mem- 
brane only. Thus the mucous membrane of the ear is in 
direct contact with the jugular vein, and there is no hin- 
drance to a direct transmission of an inflammatory process 
from one part to the other. The contiguity of the jugular 
may also show how easy it is for vascular murmurs, occurring 

* Toynbee's Catalogue, p. 44. 



THE CAVITY OF THE TYMPANUM. 1 59 

in anaemic persons for example, to be conducted to the ear, 
and be considered as originating there. 

It should also be mentioned that the pneumo-gastric 
nerve, the glosso-pharyngeus, and accessorius all pass out 
of the cranium through the jugular foramen. The hypo- 
glossal nerve also lies near the upper section of the jugular 
vein. Affections of these nerves and their sheaths, there- 
fore, are very possible in connection with inflammations 
in this region, and especially from the pressure of a large 
thrombus in the vein. 

The upper wall or roof of the cavity of the tympanum 
is covered on its upper surface by dura mater, and thus 
forms the partition wall between the cavity of the tym- 
panum and the cranium. According to the observations 
as yet made, this wall, the tegmen tympanic is most frequently 
softened, carious, or perforated, in caries of the temporal 
bone. The undeniable connection between the ear and 
secondary cerebral disease has been here most often shown. 
Sometimes it is a purulent myringitis or encephalitis ; but 
usually an abscess in the cerebral substance. In conse- 
quence of this very great practical importance of the roof 
of the cavity of the tympanum, many variations in devel- 
opment of this part become doubly worthy of notice. 
Hyrtl (professor of anatomy in Vienna), has recently called 
attention to several such cases. 2 

The roof of the cavity of the tympanum, or tegmen tym- 
pani, varies greatly in thickness in different subjects. It is 
frequently seen to be, not a dense, compact structure, but 
composed of smaller and larger cells ; and it is often so thin 
as to be translucent, and may even contain variously sized 
perforations, which may be easily mistaken for losses of sub- 

i Vide case of Beck, Deutsche Klinik, 1863, No. 48. Archiv. fur Ohrenheilkunde, III, 
S. 67. 

2 Spontaneous dehiscence of the roof of the tympanum. Sitzung's Bencht der Wiener 
Academie, XXX, B. No. XVI. 



l6o THE CAVITY OF THE TYMPANUM. 

stance produced by caries. On account of the contiguity 
of the dura mater, these abnormities may be very important 
as regards the health and life of an individual who suf- 
fers from an inflammation, or from suppuration in the 
cavity of the tympanum. In some not very rare cases of 
partial atrophy of the osseous part of the roof of the 
cavity of the tympanum, the mucous membrane and dura 
mater lie next to each other, without any intervening ma- 
terial ; and thus there is no hindrance to the transition of 
an inflammation or suppurative process from one part to 
the other. 

In addition to those cases of losses of substance in the roof of the 
cavity of the tympanum, reported by Hyrtl, the reader is referred to 
Toynbee's Catalogue, p. 42, where a number of such cases are given. 
Andreas Retsius has also reported some cases in Schmidt's Jahr- 
bucher, 1859, ^°* ll t S. x 53* Every anatomical collection of 
temporal bones will furnish evidence as to the frequency of this rare- 
faction. 

This anomaly of development may make itself known in practice 
in an unpleasant way. If, for instance, we forced compressed air 
into such a cavity of the tympanum, or an irritating fluid, in the usual 
way, a direct irritation of the dura mater, or a lifting up of it, like a 
vesicle from the bone, that is, sub-meningeal emphysema, may occur. 
Gruher 1 observed this in some experiments upon the cadaver. 

Luschka 7 - compares these alterations and perforations on the petrous 
portion of the temporal bone to the foveae glandular es of the calvarium, 
which, as is well known, are produced by the Pacchionian bodies; 
He believes that these villous-like vegetations of the arachnoid may 
also produce these rarefying effects on the roof of the cavity of the 
tympanum by pressure. Excellent as this explanation may be for 
some cases, it does not do for all ; because these rarefications of the 
bone are frequently found where the dura mater is entirely normal. 
The condition of the bony edges of such perforations sometimes 
causes us to think that a slowly acting pressure has been acting from 
within outward. 

1 Oestr. Zeitschrift fiir Prakt. Heilkunde, 1864, No. 3, S. 54. 
a Virchow's Archiv. Bd. XVIII, i860, S. 166. 



i 



THE CAVITY OF THE TYMPANUM. l6l 

There is another reason why the tegmen tympani should 
so frequently play such an important part in transferring 
an inflammation of the ear to the cerebrum. The petro- 
squamosal fissure is situated here. This is the fissure 
separating the squamous process from the petrous portion, 
through which, in the infant subject, the dura mater sends 
a very vascular process into the cavity of the tympanum, 
and along which, even in adults, a number of fine vessels, 
branches of the middle meningeal artery, pass from the 
dura mater into the middle ear. 

This fissure is largest, of course, in the child ; but a 
greater or less trace of its existence is always found in 
more developed subjects, and it is occasionally visible even 
in advanced age. This communication of the dura mater 
with the cavity of the tympanum explains the fact, that in 
the existence of hyperemia of the middle ear on the dead 
subject, the vessels of the dura mater lying over it are 
frequently found enlarged and overloaded. This intimate 
nutritive connection between the mucous membrane of the 
middle ear and the dura mater may explain many symp- 
toms, that we shall subsequently find to occur very often 
in inflammation of the cavity of the tympanum. 

The inner wall of the cavity of the tympanum is perhaps 
the most important of all of them. This, on account of 
its relation to the inner ear, may be called the labyrinthine 
wall. It forms the boundary between the middle and inner 
ear, and the important parts composing this latter portion 
lie behind it. In the labyrinth wall are found the two 
openings, which connect the parts of the auditory appa- 
ratus that conduct the sound, and those which receive it. 
These openings are the fenestra ovalis and the fenestra 
rotunda ; the former leading to the cochlea, the latter to 
the vestibule. 

The fenestra ovalis, or the fenestra of the vestibule, 
should not be considered, as it generally seems to be, as a 

21 



1 62 THE CAVITY OF THE TYMPANUM. 

simple opening in the wall, but it has some depth ; it has 
a niche, if I may so express myself, which is filled for the 
most part by the base of the stapes bone. This vestibular 
fenestra is found at the base of a funnel-shaped opening, 
looking towards the cavity of the tympanum (pelvis ovalis), 
whose mucous membrane is very near to the sides of the 
stapes. 

(This fissure or opening is produced by the prominence 
of the Fallopian canal, and the arch of the promontory.) 

The labyrinth side of the fenestra ovalis is closed by the 
periosteum of the vestibule, which covers it, and thus 
forms the membrane of the fenestra ovalis. The base of 
the stapes is united to it : since its circumference is some- 
what smaller than the fenestra itself, the outermost peri- 
phery remains open like a small seam, not being covered by 
the base of the stapes. This very small membranous ring 
around the base of the stapes, the enveloping membrane of 
the stapes, — also called annular ligament of the stapes, — 
we may best see by holding the labyrinth wall of the cavity 
of the tympanum, with the stapes in situ, towards the sun- 
light, and observing the base of the stapes from the vesti- 
bular side. It is better still to examine the parts under 
the microscope, by means of sun-light passing through 
them from beneath. — Voltolini. 

Toynbee described a perfect articulation between the stapes and the 
fenestra ovalis, stapedio-vestibular articulation, with all the parts of 
such a joint, cartilage, ligament, and synovial fluid. He gives an 
exact description of this articulation in the Medical Times and Ga- 
zette (London), June 20, 1857: "In a recently removed ear the 
surface of the base of the stapes is smooth, and covered with a fine 
layer of cartilage. It is most abundant on the two extremities, from 
which, especially in young persons, enough may be removed for a 
microscopic examination. It consists of oval corpuscles, similar to 
those in ordinary articular cartilage, only very much smaller." Toyn- 
bee here really admits, by his own words, that this is no articulation in 
the real sense of the word ; for then the two surfaces, lying opposite each 



THE CAVITY OF THE TYMPANUM. 1 63 

other, must be necessarily covered with cartilage. He also mentions 
the fact several times, that the surface of the fenestra ovalis is greater 
than that of the stapes, which fact excludes the idea of any such intimate 
connection as exists in an articulation. Nothing is said of an articular 
capsule. S. T. Sbmmering described an articular capsule, which is 
said to unite the base of the stapes and the fenestra ovalis. — (De Cor- 
poris Humani Fabrica, T. II, p. 10.) Voltolini has recently shown 
that no true articulation really exists. Where there is no articulation, 
there can be no anchylosis. We can only speak of an immobility of 
the stapes, caused by a rigid pseudo membrane, which attaches it to 
the adjacent walls, or of a thickening and calcification of the mem- 
brane of the fenestra ovalis, such as we see in the membrane of the 
fenestra rotunda. Recent German anatomists do not accept either a 
layer of cartilage at the base of the stapes, or an articular capsule, 
while A. Magnus (Virchow's Archiv^, 1861, B. XX, S. 125,) says 
that the surface of the base of the stapes, as well as the walls of the 
canal of the foramen ovalis, has a layer of the cartilage, which 
becomes less distinct in advanced life, and then only exhibits some 
indistinct cartilage corpuscles. Magnus also believes that the base 
of the stapes is by no means smaller than the surface of the fenestra 
ovalis, and that the latter is therefore completely filled up. 

Fig. 14. 

Pr. 



FR ' 
F,j, ' M, st. 

Superficial view of the labyrinth wall of the cavity of the tympanum : 
Pr, promontory, or most convex portion of the labyrinth wall. FR, 
entrance to the fenestra rotunda, or fenestra cochlea. M, st, stapes 
muscle in the bony pyramid, which is mostly opened; above, its tendon 
passing to the head of the stapes ; the stapes in the fenestra ovalis, or 
fenestra of the vestibule. N, f, facial nerve up to its curvature into the 
Fallopian canal, whose lower half is laid open, C, h, the horizontal or 
anterior semi-circular canal, opened at the most prominent part. M, t, /, 



164 THE CAVITY OF THE TYMPANUM. 

tensor tympani muscle ; a section of its tendon near the facial nerve. 
T, the uppermost portion of the osseous part of the Eustachian tube, inter- 
rupted by the carotid canal, which is laid open. C, z, internal carotid 
artery. F,j\ fossa for the internal jugular vein. 

The fenestra rotunda, or fenestra of the cochlea, lies 
under the fenestra ovalis. This also, like the fenestra of 
the vestibule, has a niche, a bony canal 1 mm. long. 
At its end is a membrane, the so-called second membrana 
tympani, which separates the tympanic orifice of the cochlea 
from the cavity of the tympanum. This canal passes ob- 
liquely from behind forward. Thus the membrane of the 
fenestra rotunda does not lie parallel with the membrana 
tympani, because this membrane, situated at the end of 
this depression, is not visible on the living subject, even 
when the whole membrana tympani is destroyed. 

The membrane of the fenestra rotunda, with the canal 
leading to it, like all the parts of the cavity of the tym- 
panum, is covered by mucous membrane. If this be thick- 
ened by catarrh of the middle ear, the passage to the 
membrane may easily be plugged up. The membrana 
tympani secondaria is also not unfrequently found thick- 
ened. Complete calcification of this membrane has also 
been observed. 

It is plain that every morbid change that lessens or re- 
moves the elasticity of this delicate structure, must thereby 
exert an extremely disturbing influence upon the hearing, 
because the mobility of the stapes, and of its membrane, 
as well as every oscillation of the fluid between the two, 
— the fluid of the labyrinth, — is limited or destroyed. Ab- 
normal conditions on the fenestra rotunda and its membrane 
seem to be very common in catarrh of the cavity of the tym- 
panum. A pseudo-membrane is sometimes found to be 
stretched over the entrance of the niche of the fenestra 
rotunda, which, on superficial examination, may be mis- 
taken for the membrana tympani secondaria. 



THE CAVITY OF THE TYMPANUM. 1 65 

Voltolini observed and reported several cases where the canal, lead- 
ing to the membrane of the round fenestra, ran, not obliquely, but in 
a straight line ; and thus the membrane became visible on the removal 
of the true membrana tympani. 

This in an adult is certainly a very remarkable anomaly. This 
parallel position of the membrane with relation to the membrana 
tympani recalls the conditions in the human foetus, and in some ani- 
mals. In the foetus of some three to four months, the fenestra ro- 
tunda lies nearly parallel to the membrana tympani. In the newly 
born, it is situated obliquely with relation to the membrane, and the 
niche is gradually turned more posteriorly towards the entrance to the 
mastoid cells. It is possible that in this case, as in that of the mem- 
brana tympani, under certain circumstances development is arrested 
in childhood. 

Anteriorly, from these two fenestra, and nearly opposite 
the membrana tympani, we find the promontory. This is 
a smooth and broad prominence, projecting somewhat into 
the cavity of the tympanum, behind which is situated the 
outermost turn of the cochlea. From this there goes a 
bony furrow, in which, under the mucous membrane, pass 
the tympanic nerve of the glosso-pharyngeus and several 
vessels. This groove or furrow varies in size in different 
individuals, like the various depressions and elevations of 
the cavity of the tympanum. 

In front of the promontory, corresponding to the opening 
of the Eustachian tube into the cavity, lies the internal ca- 
rotid artery. It is separated from the mucous membrane 
of the cavity of the tympanum only by a thin, porous, and 
often even defective bony layer. This always has irregu- 
larities on its side turned towards the cavity, so that reten- 
tion and disintegration of purulent secretion may all the 
more readily occur there. 

Caries in this wall of the carotid canal, which is besides 
perforated by numerous openings for vessels and nerves, 
not unfrequently occurs. This has led to the perforation 
of the arterial walls with subsequent fatal hemorrhage. 



1 66 THE CAVITY OF THE TYMPANUM. 

It should also be remembered that the inner side of the 
carotid canal, of the temporal bone, is covered by a redu- 
plication of the dura mater, and that there is a venous 
space, a sinus of the dura mater between the artery and 
the bony wall, which is connected with the cavernous sinus 
of the sella turcica of the sphenoid ; and, like this, it is 
crossed by a number of thread-like, and broad tendinous 
processes. As is well known, the adjacent venous sinuses, 
especially the transverse and superior petrosal, play a great 
part in the very frequent deleterious consequences of sup- 
purative otitis. If nothing of this kind has as yet been 
recognized in the venous sinus of the carotid canal, it is 
probably because the attention of pathological anatomists 
has not yet been turned to this part. It is undeniable 
that this space is more exposed to an influence from an 
inflammatory collection in the cavity of the tympanum, on 
account of its position, than the sinuses, which have as yet 
been found to be so often affected. It should, therefore, 
be always carefully examined in such morbid processes. 

This venous sinus in the carotid canal was described by 
Rektorzik in 1858. 1 

In skulls where the sinuses generally are filled with blood, the 
blood from this sinus runs out, and no inconsiderable quantity on 
opening the carotid canal. The sinus in question takes the greater 
part of its blood from the cellular blood passages, with which it is in 
direct connection. Some osseous veins also empty into it. Towards 
the entrance of the carotid canal, some small veins are formed from 
it, which terminate in several branches, and empty directly into the 
internal jugular vein. 

Immediately above and behind the fenestra ovalis is a 
longish projection, covered only by a thin and translucent, 
sometimes even defective osseous layer. This is the Fal- 
lopian canal, with the facial nerve. It comes from behind, 

• 

i Sitzung's Bericht Wiener Akademie, XXXII, B. N. 23, S. 416. 






THE CAVITY OF THE TYMPANUM. 1 67 

and runs for some distance on the posterior portion of the 
labyrinth wall. It bends at nearly a right angle on this, 
and runs towards the opening of the auditory nerve. We 
also find the facial nerve running quite near the mucous 
membrane of the cavity of the tympanum on the posterior 
wall ; but it is most intimately, and for the longest time, con- 
nected to the cavity of the tympanum on the labyrinth wall. 

Anatomy explains to us why it is, that not only in caries 
of the bone, but also in simple inflammatory and hyperae- 
mic conditions of the mucous membrane of the cavity of 
the tympanum, an affection of the facial nerve may occur. 
The facial nerve, during a portion of its course, is sepa- 
rated frqm the mucous membrane of the cavity of the 
tympanum only by a translucent bony layer, which is 
sometimes porous, or even deficient in some places, so that 
neurilema and mucous membrane are close to each other. 1 
The stylo-mastoid artery, which supplies the greater part 
of the mucous membrane of the middle ear, runs from the 
stylo-mastoid foramen in connection with the facial nerve 
in the Fallopian canal, and sends off branches to the 
envelope of this nerve, so that the two parts have a certain 
nutritive unity. 

Wilde , of Dublin, believes that he has frequently ob- 
served an obliquity of one of the angles of the mouth in 
deaf persons when the muscles of the face are in action, and 
an irregular development of the naso-labial furrows of the 
two sides. It is certain that in diseases of the cavity of 
the tympanum, the facial is very often found to be involved 
if close observation be made, It is also certain that a 
great deal of the so called rheumatic paralysis of the facial 
nerve is connected with affections of the ear, or proceeds 
from it. 

1 Henle, Handbuch der Anatomie, S. 147, states that there is almost always an oval opening 
above the fenestra of the vestibule, which is only covered by fibrous membrane. According 
to Joseph, the Fallopian canal is membranous until the fourth foetal month, on the side to- 
wards the cavity of the tympanum. 



1 68 THE CAVITY OF THE TYMPANUM. 

The stapedius muscle is between the entrance to the 
fenestra rotunda and the Fallopian canal, running concen- 
trically with the latter. This is the smallest muscle of the 
human body. It is enclosed in a scarcely developed osse- 
ous papilla, so that only its tendon, reaching to the head 
of the stapes, lies freely in the cavity of the tympanum. 

The second internal muscle of the ear, the tensor tym- 
pani, passes above the Eustachian tube, running in the 
same direction with it, anteriorly into the cavity of the 
tympanum, and there runs on the uppermost part of the 
labyrinth wall very near to the roof, or tegmen tympani. 
Immediately in front of, and above the pelvis ovalis it 
becomes a tendon, which leaves the belly of the muscle at 
an obtuse angle, and passes obliquely over the cavity of 
the tympanum to be inserted on the malleus, as has already 
been described. This muscle lies in a bony canal that 
is sometimes half closed, but oftener completely so ; * so 
that in the latter case the tensor tympani is as completely 
surrounded by bony substance as its partner, the stape- 
dius. 

Behind the facial nerve, about on a level with the fenestra 
ovalis, that is, in the uppermost and most posterior por- 
tion of the labyrinth wall, the anterior or horizontal semi- 
circular canal curves over, having the vertex of the curva- 
ture in the cavity of the tympanum. It may be recog- 
nized by the marked whiteness and smoothness of its 
compact osseous material. 

There have been several cases observed where caries at 
this point opened the semi-circular canal, so that the sup- 
purative inflammation passed out of the cavity of the 
tympanum into the vestibule, and passing into the cribri- 
form bony camellae, through which the twigs of the auditory 
nerve pass, was continued into the meatus auditorius internus, 

i Vide Ludw. Mayer Studien iiber die Anatomie des Canalis Eustachii, Miinchen, 1866, 
s. 34-37- 



MASTOID CELLS EUSTACHIAN TUBE. I 69 

by which all the requirements for an inflammation of the 
meninges of the brain were fulfilled. 

Since, in such a transference of a suppurative inflamma- 
tion from the cavity of the tympanum to the labyrinth, — 
whether by the destruction of the horizontal semi-circular 
canal or through a perforation of the fenestra rotunda or 
ovalis, — the petrous portion of the temporal bone may 
possibly bear no evidence of morbid change, even after the 
removal of the dura mater ; and since the roof of the cavity 
is not involved in such an affection, the true connection 
may be easily overlooked, and the meningitis may be mis- 
taken for the primary idiopathic affection, when it is really an 
otitis. We should, therefore, be on our guard if we observe 
even a very slight amount of pus in the internal meatus, and 
break open the labyrinth from above, where the distinct 
traces of inflammation will show the true state of things. 

Mastoid Cells. — The opening of the mastoid cells is 
found on the posterior wall. This opening is very often 
divided into several. These lead into a hollow space, 
which is developed in childhood and makes up the upper 
or horizontal part of the mastoid process. The mastoid 
cells, like the opening that leads to them, lie close under 
the roof of the cavity of the tympanum. 

Eustachian Tube. — About on the same level, but on 
the anterior extremity, the Eustachian tube opens into the 
cavity of the tympanum. This opening, or ostium tympani- 
cuni, lies in the upper third of the cavity of the tympanum, 
and exactly opposite the opening into the mastoid cells. 
A probe passed through the tube and cavity of the tym- 
panum will finally pass into these cells. The same thing will 
occur if fluids are injected, if the injection be done with suffi- 
cient force, and if they are pressed forward in such a quantity 
that they do not vaporize before reaching the point desired. 
22 



I70 TOPOGRAPHY OF CAVITY OF TYMPANUM. 

Topography of the Cavity of the Tympanum. — We may 

finally consider the topography of the cavity of the tym- 
panum, in its relations to the membrana tympani, in order 
that we may have a clear idea as to which parts correspond 
to each other, and which we may see through a perforation 
of the membrana tympani, or, under certain circumstances, 
through the drum itself, when it is very transparent, or lies 
abnormally inwards. 

The examination of a great number of macerated skulls 
shows that the outer opening of the cavity of the tympanum, 
which is usually closed by the membrana tympani, is just 
as differently shaped, as we have seen that it is from a section 
of the osseous meatus. We therefore may see in one skull 
parts of the labyrinth wall from without, which, on other 
skulls, are only seen partially or not at all. This is some- 
times the case with the fenestra ovalis, for example, which, 
in some skulls, is situated in a position corresponding to 
the upper and posterior portion of the membrana tym- 
pani, but, as a rule, lies higher than this ; so that it cannot 
be seen on the living subject from without, even when the 
membrana tympani is entirely gone. 

The case is different with the stapes, which is fastened 
in the fenestra ovalis. Its position is somewhat sunken 
from above downwards, so that its head lies higher than 
the base. We may, therefore, not unfrequently get a view 
of a portion of this bone when there has been extensive 
loss of substance in the membrana tympani. Sometimes 
the head of the stapes, with the posterior side, is adherent 
to the unperforated membrana tympani, or lying so near 
to it that we may distinctly recognize this part of the bone 
on the posterior half, somewhat above the center of the 
membrane. 

The fenestra rotunda corresponds to the lower and pos- 
terior portion of the drum. We have already seen that 
we are usually only able to recognize the entrance to its 



MEASUREMENTS OF THE CAVITY. 



I 7 I 



niche, especially the anterior edge of it, but that we cannot 
see the membrana tympani secondaria. The promontory 
lies opposite the center and anterior and lower portion of 
the membrana tympani. It is very often completely seen, 
together with its vessels, when a portion of the membrana 
tympani is destroyed. 

Measurements of the Cavity. — In order to properly 
estimate the pathological processes occurring in the cavity 
of the tympanum, and especially those of an adhesive na- 
ture, we must consider a little more exactly the different 
diameters of this space, and the distances at which the in- 
dividual parts are from each other. 

The cavity of the tympanum, viewed as a whole, and 
apart from the irregularities of the surfaces of its walls, 
may be compared to a low and very small hexahedron or 
cube. The horizontal diameter of this cavity is therefore 
the greatest. It is about 13 mm. 

Fig. 15. 




- M, a, e. 



Vertical section of the cavity of the tympanum, continued through the 
membrana tympani and auditory canal : Left ear. M, a, e, bony exter- 
nal auditory canal; at its end the membrana tympani with the malleus. 
D, m, dura mater, covering over the upper wall of the cavity and of the 
meatus containing air cavities, as well as the whole of the inner surface 



172 MEASUREMENTS OF CAVITY OF TYMPANUM. 

of the petrous portion of the temporal bone. C, m, head of the malleus, 
connected by its suspensory ligament to the roof of the cavity of the tym- 
panum ; to the median side of the malleus is the incus with its long or 
vertical process, articulating with the stapes ; only the head of the stapes 
is to be seen. N,f, facial nerve, divided just after its right angular 
curvature. M, t, t, tensor tympani muscle, divided just before its tendon 
is given off-, the latter is to be seen in its entire course from the labyrinth 
wall to the neck of the malleus. V, vestibule, with the orifice of a semi- 
circular canal. C, cochlea, with the membrane of the fenestra rotunda; 
outwards (laterally) the promontory. F, J, fossa for the internal jugular 
vein, forming the very thin floor of the cavity. 

The hight or the vertical diameter, anteriorly at the 
tympanic orifice of the tube, is only from 5 to 8 mm. ; 
further back, at the malleus, it is 15 mm. The distance 
from the membrana tympani to the labyrinth wall is the 
least. At the mouth of the tube it is from 3 to 4J mm. ; 
but if we measure somewhat further back in the vertical 
plane of the malleus, we get only 1 mm. at the end of the 
handle of the malleus, which projects very much into the 
cavity of the tympanum. This is, of course, the most 
convex portion of the drum, corresponding to the most 
concave portion externally, — the umbo. 

The length of the tendon of the tensor tympani muscle, 
from its beginning on the processus cochleariformis to its 
insertion, is from 2I to 3 mm. ; further backwards, to- 
wards the mastoid process, the cavity of the tympanum 
becomes wider again, and measures about 6 mm. 

The two ossicula auditus, incus, and stapes, proceed 
from walls lying opposite, and the head of the latter lies 
only 3 mm., and the end of the long process of the incus 
only 2 mm. from the posterior half of the membrana tym- 
pani. It should also be mentioned that the head of the 
malleus lies at a variable but always a short distance from 
the roof of the cavity ; and that the broad surface of the 
incus lies very near the outer wall of the cavity of the 



MUCOUS MEMBRANE OF CAVITY. I73 

tympanum. There is also an extremely small" distance 
between the sides of the stapes and the bony walls of the 
pelvis ovalis. 

All these parts are covered by a mucous membrane 
which, like every other mucous membrane, is subject to 
inflammatory swelling, thickening and infiltration. At 
every attack of catarrh of the cavity of the tympanum 
the measurements that have just been given must become 
smaller to a certain extent. The space may be even en- 
tirely filled up when there is very great or repeated swelling 
of the membrane, so that some structures that have pre- 
viously been separated come in contact with each other ; 
and thus the space is rendered very much smaller. From 
this occasional contact of the swelled parts of the mucous 
membrane, adhesions may occur, especially when suppura- 
tion of the ear has taken place, or abnormal attachments 
or pseudo-membranes may be found. 

Numerous variations may occur in different persons, in accordance 
with the measurements of different authors. In some skulls a very 
large cavity of the tympanum is found, in others a very small one. 
The greater number of the above measurements I obtained by making 
transverse sections, in which I sawed through the level of the pyra- 
mid, and came upon the membrana tympani as nearly vertically as 
was possible, preserving it and the outer wall. Such a section is seen 
in figure 15. But here, on account of greater distinctness, the section 
is continued through the membrana tympani and the auditory canal. 

Mucous Membrane, — The lining of the cavity of the 
tympanum, as is well known, is a continuation of the mu- 
cous membrane of the Eustachian tube, and of the naso- 
pharyngeal space. The mucous membrane is smooth, 
whitish, very thin and delicate. In adults, in some re- 
spects, it is more like a serous membrane. Its epithelium 
consists of pavement cells, which, according to Kollikers 1 

1 Wiirzburg Verhandlungen, 1855. 



174 CAVITY OF TYMPANUM IN THE FCETUS. 

observations, made upon a person who had been hanged, 
exhibited a ciliary motion, except the inner surface of 
the membrana tympani and the ossicula. This is most 
decided on the floor of the cavity, where I also succeeded 
in finding them, and where the epithelial cells seemed a 
transition between flat and cylindrical cells. The exist- 
ence of glands has as yet been denied. I have, however, 
found a racemose gland of quite a large size close to the 
membrana tympani, where the tube and cavity pass into 
one another. I have never found any glandular elements 
in the remaining portions of the cavity. The observa- 
tions of Luc<e x render it probable, however, that glands may 
exist in abundance in this part. 

The mucous membrane and periosteum cannot be sepa- 
rated in the cavity of the tympanum. The membrane, 
that we are accustomed to call mucous, is at the same time 
the carrier of the vessels for the bones. It takes the place, 
in other words, of a periosteum. This relation is one of 
importance, since every severe and long existing affection 
of the mucous membrane will react upon the nutrition of 
the bones forming the cavity of the tympanum. Every 
inflammation of the mucous membrane of the cavity is at 
the same time an inflammation of the periosteum. Every 
catarrh is a periostitis. If the inflammation has a chronic 
course, there is a greater tendency to thickening of the 
mucous membrane, and to hypertrophy of the bones, — to 
hyperostosis. In acute affections, as is well known, the 
mucous membrane is more inclined to ulcerate, and the 
periostitis more frequently leads to atrophy of the bones, 
inflammatory softening, and superficial caries. 

Cavity of the Tympanum in the Foetus. — In the foetus 
the cavity of the tympanum, like the lungs, contains no air. 
All the anatomists since Fabricius ab Aquapendente assert 

i Virchow's Archiv. XXIX, S. 7. 



CAVITY OF TYMPANUM IN THE FCETUS. 1 75 

that it is filled with mucus. Huschke 1 states: "The 
cavity of the tympanum in the newly born, as well as in 
the foetus, is still filled with mucus ; and it is only after 
breathing and crying have been carried on for some time 
that the air passes through the Eustachian tube, and drives 
this mucus out." If "mucus," be considered as free tissue, 
as the product of a mucous membrane, this view is deci- 
dedly incorrect. There is no free mucus in the cavity of 
the tympanum of the foetus and the newly born, but it is 
filled by a swelling of the mucous coat, especially of that 
covering the wall of the labyrinth, which extends like a 
thick cushion to the smooth inner surface of the mem- 
brana tympani, upon whose surface it lies closely. This 
cushion, which on section is muco-gelatinous in structure, 
has a vascular surface, and is covered by a beautiful nuclear 
polyonal and smooth epithelium. It consists of embryo- 
nal connective tissue (Virchow's mucous tissue), of a 
beautiful cellular net work in a mucous basis. This cushion 
of mucous membrane becomes smaller soon after birth, 
partly through shrinkage, partly by increased desquama- 
tion, and deliquescence proceeding from the surface, and 
thus room is made for the air. 

According to several observations on children who died during 
parturition, or a little while before, the lessening in size of this cushion 
filling up the cavity of the tympanum was begun before birth. In 
such cases we find many epithelial cells in the cavity, filled with fat 
granules. 

This existence of the mucous cushion in the cavity, 
which, so far as I know, I was the first to exhibit, may 
contribute to explain why affections of the middle ear are 
so very common in small children ; a subject to which I 
shall devote more attention in a subsequent lecture. 

1 Sommering's Anatomie, 1844, S. 897. 



I76 OSSICULA AUDITUS. 

Ossicula Auditus. — It is well to notice, in regard to 
the ossicula, that they are developed at a very early period. 
They may be seen as early as the beginning of the third 
embryonal month. They are then cartilaginous, and the 
incus cannot be plainly distinguished from the stapes ; but 
they are comparatively large at this period. 

Their ossification begins before the end of the third 
month. In the fourth foetal month, the lower portion of 
the malleus, from the neck on, consists of transparent car- 
tilage, but the head has a thin bony shell. In the incus, 
the posterior and greater part of the articular surface, and 
the whole posterior (short) process is formed of reddish 
flexible cartilage. The stapes, at this time, is still com- 
pletely cartilaginous, and only has an osseous point at its 
base and in each side. It is more than two-thirds as large 
as in an adult. 

In the foetus of the sixth or seventh month, the stapes 
is fully ossified ; while on the incus a thin, soft layer of 
cartilage may be separated from the cartilaginous surface, 
and the lowest portion of the handle of the malleus is still 
cartilaginous. In a foetus at the beginning of the ninth 
month, the ossicula are fully ossified ; yet the dense, 
bony layer on the surface is very thin, and, within the 
reticular tissue, extremely delicate. The size is the same 
as in adults. 

The compact osseous substance increases in density 
with age, so that in subsequent years the spongy tissue 
has completely disappeared. 



LECTURE XII. 

II. ANATOMY OF THE MIDDLE EAR. 

The Mastoid Process. 

The horizontal and the vertical portion. 

The Eustachian Tube. 

Formation and length ; isthmus of the tube ; tympanic orifice ; 
pharyngeal orifice ; construction of the cartilaginous portion ; 
mucous membrane ; caliber ; the muscles of the tube and their 
function. 

Vessels and Nerves of Middle Ear. 

Gentlemen : Turning to the mastoid process, we find 
it to present the appearance of an appendage or appendix ; 
a kind of air reservoir of the cavity of the tympanum. 
The bony cells of the mastoid process are not filled with 
marrow, but with air. The mastoid process may be divided 
into two parts. First, the horizontal part (antrum mas- 
toideum 1 ), which consists of one or more large cells, and is 
situated close behind and above the cavity of the tympanum, 
and therefore immediately below the tegmen tympani. It 
is developed in the child, and is always found as a large 
, hollow cavity in the adult. In its normal condition it 
contains air ; in pathological states, it is lined by greatly 
thickened mucous membrane, and often filled with fluid or 
inspissated pus, or with masses of epithelium containing 

1 Joseph considers the name ''upper cavity of the tympanum" as more appropriate, since 
this space has no relation to the mastoid process. 

2 3 



178 THE MASTOID PROCESS. 

cholestearine. The second part, the real process, is situated 
further down, and more superficially. In the adult it con- 
tains a complete system of bone cavities, of smaller and 
larger dimensions. This latter, or the vertical part, is the 
one which is usually or especially understood by the term 
" mastoid process." During childhood it is small and 
flat, and consists only of spongy bone tissue, and does not 
become fully developed till puberty ; but even in adults 
its density varies very much, since at times, the compact, 
and at other times the spongy tissue, predominates. Some- 
times the cavities are very large, at another, they are only 
of small dimensions, provided with delicate or dense par- 
titions. This process frequently becomes sclerosed or 
indurated, especially in old subjects, and is then converted 
into a dense bony mass, with scarcely any cavities. In 
other cases, of course in advanced age, all the air cells of 
the temporal bone are very largely developed. 

The thickness of the compact cortical lamina differs as 
well towards the cavity of the cranium, as towards the sur- 
face of the body. Cases of remarkable attenuation of both 
sides, even actual holes, have been observed, which may 
become of practical importance. Thus the posterior wall 
towards the sigmoid groove of the transverse sinus, and 
the upper, towards the superior, petrosal sinus, are often 
so attenuated as to be transparent, or even perforated. 
These abnormities would become of great importance in 
inflammation of the middle ear, since the thin and bony, 
or even only membranous partition would readily permit 
the extension of the morbid process to the venous sinuses 
of the dura mater. The same rarefaction shows itself occa- 
sionally in the outer laminae of the mastoid process, and 
explains the origin of many cases of sub-cutaneous emphy- 
sema which occur either spontaneously or after slight 
violence to the region of the ear, and spread over a large 
portion of the head. This emphysema is caused by air 



THE MASTOID PROCESS. 1 79 

which has forced itself through the cells of the mastoid 
process under the pericranium, and into the surrounding 
cellular tissue. Similar cases of emphysema have been 
observed to follow injuries of the anterior wall of the 
frontal sinus; and it is conceivable that in an individual 
with such a defect in the outer lamina of the mastoid pro- 
cess, if he were subjected to catheterization, the effect of 
the air douche might, without any fault on the part of the 
surgeon, readily spread over the entire half of the face. 

For further information concerning the emphysematous tumors, 
se'e Hyrtl, and also the statement of Prof. Costes, of Bordeaux, of 
which extracts were communicated in the Wiener Med. Wochen- 
schrift, 1859, ^°* 5 1 * The mastoid process is one of those parts in 
which the primitive cartilage disappears at a very late period. In 
children seven months old there is still seen a thin cartilaginous cover- 
ing extending from just back of the posterior circumference of the 
annulus tympanicus over the anterior part of the mastoid process. 
At the same time, the styloid process also, still consists of a thin 
opalescent stripe of cartilage, which is movably enclosed in a strong 
tendinous sheath. 

Upon the mastoid process behind and below the ear, 
and immediately above the insertion of the sterno-cleido- 
mastoidus muscle, are situated one or more lymphatic 
glands (glandule sub-auricular is, according to Arnold). 
When the ear is inflamed, and occasionally also when it 
is not, these glands become swollen, tender upon pres- 
sure, and at times even suppurate. 

The mastoid portion of the temporal bone is perforated 
by numerous foramina, which transmit the perforating 
branches of the middle meningeal artery, and the vasa 
emissaria santorini. This fact is of importance as regards 
the abstraction of blood from the parts, since through 
these vessels communication is established between the 
■ arteries and veins in the outer surface of the skull, and 
the dura mater and its sinuses. 



l8o 'THE EUSTACHIAN TUBE. 

Eustachian Tube. — The Eustachian tube, which most 
anatomists suppose to be the remains of the first embryonal 
branchial fissure, establishes a communication between the 
pharynx and the cavity of the tympanum. It serves as 
an outlet for the secretion of the latter, but especially as a 
passage for the renewal of the air in the middle ear. It is 
therefore a ventilation tube, by means of which the meeting 
of strata of air of equal density before and behind the 
drum is made possible, and the air in the tympanum main- 
tained of the same degree of tension as that of the external 
atmosphere. 

In its structure it resembles the external auditory canal ; 
for it is also divided into a bony and a cartilaginous por- 
tion. But the proportionate length of the different parts 
is here opposite to that which obtains in the auditory 
canal. In the latter the cartilaginous canal constitutes but 
a third of the whole. It amounts in the Eustachian tube 
to two-thirds, and is therefore much longer than the bony 
portion. The average length of the Eustachian tube is about 
i J inches, or, more accurately, 35 millimeters, of which 
24 belong to the cartilaginous and 11 to the osseous por- 
tion. It must not be imagined, however, that the bounda- 
ries of these two portions are very sharply defined. The 
cartilaginous portion, especially, extends anteriorly and 
laterally farther towards the cavity of the tympanum than 
it does posteriorly and towards the middle; and thus the 
osseous canal commences sooner at this point, while the 
lower part of the tube projects laterally into the pharynx 
as a prominent swelling. The cartilaginous portion passes 
upward into the fibro-cartilaginous mass at the base of the 
brain, without very sharply defined margins ; and the walls 
of the osseous portion are an immediate continuation of 
the walls of the cavity of the tympanum. 

The Eustachian tube is narrowest where the cartilaginous 
portion is united to the bone. (Here it is 1 mm. high, 



THE EUSTACHIAN TUBE. , l8l 

and i mm. wide.) This point may be called the isthmus 
of the tube. From this point it widens in both directions. 
At its widest point — the pharyngeal orifice — it measures 
9 mm. in night ; in breadth, 5 mm. At the tympanic 
orifice, or opening into the cavity of the tympanum, the 
hight of the caliber is 5 mm. ; the breadth 3 mm. 

The aperture of the tube into the tympanum, the os- 
tium tympanicum, or tympanic orifice, as is known, is not 
situated on the floor of the cavity, or in its lower portion, 1 
where one would expect to find the opening of a tube of 
exit, but very near the roof of the cavity, and immediately 
opposite the entrance of the antrum mastoidum. The 
center of the pharyngeal orifice, which in the adult is 
shaped like the mouth of a trumpet, projects into the 
pharynx, has a gaping orifice, and usually lies on a 
level with the posterior extremity of the inferior inturbi- 
nated bone, and therefore a little higher than the floor of 
the nasal cavity. Many variations are, however, seen in 
the relations of these parts to each other. Occasionally 
the rounded end of the inferior inturbinated bone extends 
to the opening of the tube, so as to cover it. In cases 
of hyperemia of this very vascular and highly erectile 
membrane, this may be of considerable influence on the 
condition of the tube. 

As we have seen, the cartilaginous auditory canal is not 
composed entirely of cartilage ; and just so the cartilage of 
the Eustachian tube forms only a gutter, which is con- 
verted into a true tube by being closed by membrane. 
The cartilage of the tube consists of a median and a lateral 
plate, as is best seen in a transverse section of the same. 
The median plate, which is several times larger and broader 
than the lateral, which is but small, is of a very irregular 
and changeable form. On the whole, it resembles a nearly 
equilateral triangle with rounded angles, with its base 

1 In birds the Eustachian tube commences at the floor of the cavity of the tympanum. 



l82 



THE EUSTACHIAN TUBE. 



pointing downwards, and towards the median line. The 
lateral plate is inserted into the upper and outer part of the 
middle plate in the shape of a delicately bent hook {Rii- 
dinger), below which the caliber and mucous membrane of 
the tube still extend for some distance upward. 

The whole of the cartilage of the Eustachian tube, the 
middle plate of which is in immediate relation with the 
fibro-cartilaginous mass at the base of the skull, from which 
it is, however, distinguished by a pretty sharply defined 
curve of more homogeneous appearance, lies obliquely, so 
that the hook-like cartilage, which is attached to the upper 
part, points outward and downwards. As the middle car- 
tilage plate is much larger than the lateral hook-like 
cartilage, a pretty extensive space beneath the latter remains 
free, which is filled up with a non-cartilaginous soft tissue. 

Fig. i 6. 



CJ. 



M. ss. 



T.m. 



F.sp. 




Transverse section of cartilaginous portion of Eustachian tube at about 
the middle ef its course (magnified five diameters) : C. m., middle car- 
tilage. C. /., lateral cartilage (hook-cartilage). T. m., membranous 
portion of tube, passing downwards into the salpingo-pharyngeal fascia 



THE EUSTACHIAN TUBE. I 83 

(i^. sp). M, mucous membrane lining the middle cartilage, and contain- 
ing many glands. M. ss. , spheno-salpino-staphylinus muscle (abductor or 
dilator of the tube). L. p., Levator palati muscle ; {this muscle is fre- 
quently separated from the lower end of the fissure of the tube by much 
thinner intermediate tissue than it is in this case.) 

The so-called membranous portion of the tube com- 
mences at the upper part of the inner side of the hook 
cartilage. It is at first quite thin, but increases in thick- 
ness as it proceeds downwards to join the salpingo-pha- 
ryngeal fascia, which at this point of junction is pretty 
thick, but gradually becomes thinner. In adults, this 
membranous portion is the smaller half of the whole cir- 
cumference of the tube, since it makes up, apart from the 
cartilaginous hook portion, the entire lateral wall, and 
usually, also, the lower wall, or the floor of the cartilagi- 
nous tube. 

The mucous membrane of the tube, as is well known, 
is an immediate continuation of the naso-pharyngeal mu- 
cous membrane. At the pharyngeal orifice it is very thick, 
puffy, folded, and contains a great number of grape-shaped 
mucous glands, whose openings may be generally distin- 
guished with the naked eye. From the pharyngeal orifice 
upward, the mucous membrane loses more and more of its 
density ; but it is always thicker on the inner side of the 
median cartilage than on the inner surface of the membra- 
nous wall. On the tympanic orifice it is again thicker and 
more vascular, and also contains a few quite large grape- 
shaped glands. Ludw. Mayer found vascular net-work on 
the floor of the bony tube, consisting chiefly of large vessels 
anastomosing with each other. According to Rudinger, 1 
the mucous glands of the tube, as well as those of the 
upper portion of the pharynx, are traversed by numerous 

1 Rudinger (Ein Beitrag zur Anatomie und Histologic der Tuba Eustachii), and Henle, 
(Handbuch, II, 3, S. 755), assert that the whole of this part of the wall of the tube consists 
chiefly of fat. I have only found much of it in the lowermost portion.. 



184 THE EUSTACHIAN TUBE. 

nerves in a net-work ; and these nerve twigs are intersected 
by ganglia. The epithelium of the tube is ciliated, and 
the movement is towards the pharynx from the cavity of 
the tympanum. On the cadaver we often find, throughout 
the whole length of the tube, abundant mucous secretions, 
always mixed with cylinder epithelium, which has been 
thrown off, whose cilia may be seen as a rule sometime 
after death. 

The Eustachian tube of the child differs in many respects 
from that of the adult. In the first place, it is to be ob- 
served that the two portions differ less in their length, 
and that consequently the osseous portion is here com- 
paratively longer than in the adult. Taken as a whole, it 
is much shorter, and at the same time is not only^rela- 
tively but absolutely wider at its narrowest point. Its 
opening into the cavity of the tympanum is also much wider 
than it is in the adult ; and we might therefore conceive 
that a discharge of purulent secretion might frequently 
take place during childhood. On the other hand, this 
tube is placed nearly horizontal in children, while in adults 
it is inclined from above downwards. The mucous mem- 
brane frequently exhibits folds which are placed at tolerably 
regular intervals. The cartilage has not yet the form which 
it subsequently assumes ; the pharyngeal orifice does not 
protrude so much into the pharynx, and the narrow lips of 
the chink-like opening usually lie in such close contact 
with each other, that it is frequently very difficult to find 
it in the swelled mucous membrane of the pharynx in post 
mortem examinations of children. This is also the reason 
that in catheterization of the child, the posterior lip of the 
cartilage is much more rarely felt than in the adult, in whom 
it projects in the form of a pad (Wulst) into the pharynx; 
and for the same reason, closure of the tube near its pha- 
ryngeal orifice can be the more readily developed in the 
child during an inflammatory swelling of the pharyngeal 



THE EUSTACHIAN TUBE. I 85 

mucous membrane. A very beautiful view, strikingly con- 
trasting with the surrounding substance, is presented here 
by a transverse section of the cartilage of the tube. Since 
the middle plate expands less from above downwards, the 
two plates resemble a staff with its upper end bent in the 
shape of a crosier. Whilst the membranous wall in the 
adult forms the smaller half of the entire circumference of 
the tube, it occupies by far the greater half in the infant. 
This is due to the more developed condition of the lower 
wall or floor of the Eustachian tube. In consequence of 
the smaJlness of the hook cartilage, the soft or membranous 
portion occupies nearly both sides of the irregular triangle. 
This condition at the same time explains the expansibility 
or width of the tube in the child, while its great narrowness 
at the pharyngeal orifice is due to the yet very slight de- 
velopment in the breadth of the middle cartilaginous plate. 
The question of the caliber (lumen) of the cartilaginous 
portion of the tube is of great importance ; that is whether 
its walls usually gape, and are separated from each other, 
or whether, in repose, they lie in contact with each other, 
special force being required to separate them. Without 
referring to the osseous tube, which, so long as its lining 
membrane is in a physiological condition, contains air the 
same as the cavity of the tympanum, the walls of the pha- 
ryngeal extremity of the tube are separated from each other 
like a funnel ; and there exists, furthermore, at the point 
of junction of the osseous and cartilaginous portions for a. 
short distance beneath the hook cartilage, a small space 
filled with air. In the remaining, that is, the greater part 
of the cartilaginous portion, I have never been able to 
find anything of a free space, that is commonly open. 
On the contrary, the mucous surfaces of the middle and 
the lateral wall lie here against each other throughout their 
L entire length, so that only a somewhat long, often slightly 
S shaped, curved fissure exists between them. 
24 



I 86 THE EUSTACHIAN TUBE. 

According to Riidinger's description and plate there exists, below 
the hook cartilage in the uppermost part of the fissure of the tube, 
a free and rounded space, constantly filled with air, which is formed 
and bounded below by two valvular projections of the mucous 
membrane, opposite to each other, and which are always present, 
and cannot be smoothed down. Although I have made many sec- 
tions of previously hardened preparations, I have never been able to 
convince myself of the presence of such a free space, without regard 
to the uppermost part of the cartilaginous tube ; nor have I ever been 
able to see positively the membranous valves described by Riidinger. 
Luc<e x also could not convince himself of the latter ; while, according 
to him, there is a free space under the cartilaginous hook. My re- 
searches in comparative anatomy, which I made for this purpose in 
various mammiferous animals, moreover speak decidedly against the 
presence of a constantly open space in the tube \ for, notwithstanding 
the great variety prevailing in the arrangement and shape of the car- 
tilaginous and membranous portions of the tube in different animals, 
the walls were always found to be constructed in such a way as to 
necessitate their lying against each other through their entire length. 
Sections of the Eustachian tube of carnivora are most instructive on 
this point. Very recently Riidinger z has published some observations 
on the comparative anatomy of the tube, which verify this idea as to 
the existence of a free space in its uppermost part. 

This fissure, in the lowest part, 8-9 millimetres high, 
decreases in length in the upper part, and can, near the isth- 
mus of the tube, be dilated to 1J-2 millimetres at the most. 
(This is the rule ; there are, however, some remarkably 
wide tubes.) That the walls ordinarily lie but lightly 
against each other, is made apparent by a consideration of 
the physiological importance of the tube as a duct lined 
with ciliated epithelium for the discharge of the secre- 
tions of the cavity of the tympanum. This is furthermore 
proved by the fact, that a very slight pressure of air, such 
as, for example, results from eructation, often suffices to 

i Zur Function der Tuba Eustachii, Archiv. fur Ohrenheilkunde, III, S. 174, Beitrage 
zur Anatomie der Ohrtrompete, L. C, B. II, S. 217. 
a Monatschrift fur Ohrenheilkunde, No. 1, Oct., 1867. 



THE EUSTACHIAN TUBE. I 87 

separate the walls from each other, so that we feel the air 
entering into the ears. It is also well known that in cases 
of perforation of the drum, the fluid injected without any 
force into the external meatus frequently escapes through 
the Eustachian tube into the pharynx. 

But if this tube is at the same time to be a ventilation 
tube, by means of which a regular exchange of air be- 
tween the pharynx and the cavity of the tympanum is 
brought about, it is necessary that its regular and frequent 
gaping or opening should take place only in this wise, that 
the strata of air, before and behind the membrana tympani, 
be kept of the same tension and density that is requisite for 
a normal vibratory capacity for the drum ! Experience 
has shown that such an opening of the tube takes place 
with every act of deglutition. You may experience this 
upon yourselves, if you at first swallow a few times with 
mouth and nose closed, and afterwards swallow with these 
cavities open. While you at first dilute the air in the 
cavity of the tympanum, the membrana tympani moves 
inwards, and you perceive, beside some noises, a feeling 
of pressure and fullness in the ear, which gives way to the 
normal sensation as soon as, by swallowing with the nose 
open, we permit the air of the cavity of the tympanum to 
equalize itself with that of the pharynx. You may also 
readily convince yourselves of the influence exerted by the 
act of deglutition upon the Eustachian tube, by examining 
a patient. In auscultating the ear whilst air is being 
injected through the catheter, you will hear the entering of 
the air much more distinctly at the moment when the pa- 
tient swallows ; and the patient himself will also, at the 
same time, feel the air much more forcibly in his ear. 
Other proofs of the opening of the tube during deglutition 
we shall learn hereafter. 

How, now, are the motor forces arranged which bring 
about this temporary gaping of the tube? The majority 



I 88 MUSCLES OF THE EUSTACHIAN TUBE. 

of anatomical authorities either pay no attention at all to 
the relations of the upper muscles of deglutition — the ten- 
sor, and the levator palati — of the Eustachian tube, or else 
allude to them only incidentally. But amongst the few 
that have recognized these muscles as muscles of the tube, 
and also have subjected their action to a close scrutiny, 
very different views prevail as regards the details. In view 
of the great importance of this subject, I consider it a duty 
to treat of it as fully as possible, just as it has been re- 
vealed to me by my anatomical investigations. 

Muscles of the Tube. — The spheno-salpingo-staphylinus, 
or circumflexus palati, or tensor palati mollis muscle, arises 
not only from the sphenoid bone, but a large portion of 
its fibers take their origin from the outer and under surface 
of the lateral hook cartilage, as well as from the contiguous 
portion of the membranous wall of the Eustachian tube. 
A little further downwards the posterior surface of the thin 
and flat belly of this muscle lies in so close and intimate 
contact with the membranous tube, and is, by means of 
short and tense connective tissue, so closely interwoven 
with it, that it is very difficult to separate the tube from 
this muscle. Towards the pharyngeal orifice the fibers of 
the muscle can be more easily separated from it, while in its 
upper part, towards the osseous portion of the tube, the 
union with the membranous portion becomes more and 
more intimate, and the number of fibers evidently arising 
here, constantly increases. Furthermore, there exists, also, 
a very close relation between this muscle and the fascia, 
with which, as we have already mentioned, the lowest por- 
tion of the membranous wall, at its outer part, becomes 
united. As this fascia arises from the entire length of the 
membranous tube, and passes backwards and downwards 
to the latero-posterior wall of the pharynx, it may with 
propriety be denominated the salpingopharyngeal fascia. 



MUSCLES OF THE EUSTACHIAN TUBE. I 89 

Whilst the said fascia passes beneath the under surface of 
the tensor palati muscle the fibers of the same do not only 
lie in very close contact with it, but a few of them also 
take their origin here, which is especially noticeable at its 
upper part, where this layer of connective tissue, having 
constantly increased in thickness, is inserted into the pe- 
trous portion of the temporal bone. 

The muscle itself passes downwards and outwards at an 
acute angle to the axis of the tube and its tendon, and as 
you are aware, winds round the hamular process. As soon, 
now, as its lower extremity reaches a point of fixation, 
contraction of its fibers must result in the drawing down- 
wards and outwards of its upper points of insertion, so far 
sa they are movable. These are, first, the lateral cartilage, 1 
the hook cartilage. Secondly, the membranous wall of 
the tube ; the latter must be drawn particularly in the 
before mentioned directions at its lower expanded termina- 
tion, by the salpingo-pharyngeal fascia. Contraction of the 
spheno-salpingo-staphylinus muscle consequently ought to 
draw the entire lateral, partly cartilaginous, and partly 
membranous wall of the tube away frqm the middle wall, 
and thus produce gaping of the canal of the tube. Accord- 
ing to experience, the latter takes place with every act of 
swallowing; and we must therefore assume that, with this 
act, all the conditions have been supplied to allow the 
drawing-down action of the muscle just described to become 
effective; that is to say, the conditions which afford to those 
of its fibers which arise from the lateral wall, a fixed point 
below, and at the same time stretch the salpingo-pharyngeal 
fascia in a downward direction. 

This process may be illustrated on the cadaver, by pulling on the 
belly of the muscle. At the same time, especially if the movement 

1 RUdinger first stated that this cartilage is movable. This anatomist has, by teaching the 
study of the conformation of the tube from sections, rendered very essential service in the 
investigation of this subject. 



I90 MUSCLES OF THE EUSTACHIAN TUBE. 

be made rapidly, and the mucous surface be well moistened, that pe- 
culiar cracking noise is heard, which was formerly supposed to be 
located in the middle ear, and was thought to be the result of the 
contraction of tensor tympani, until Politzer 1 experimentally proved 
its true cause. 

Such proof very readily results from a consideration of 
the process of deglutition. During the act of swallowing 
the soft palate is, by means of the lower muscles of the 
palate, the glosso-palatini, and especially by the more pow- 
erful pharyngo-palatini muscles, stretched in a downward 
and backward direction, and pressed against the posterior 
wall of the pharynx, so that it obtains a fixed position. 
But, as with the act of deglutition, a contraction takes 
place simultaneously in the antagonists of the muscles 
under consideration, the upper muscles of the pharynx 
(the tensor and the levator palati) will change points of 
fixation and attachment in such a way that the soft palate 
becomes the (relatively) fixed point, and the lateral, mova- 
ble wall of the tube, on the other hand, the point of origin 
of the muscular fibers from which motion proceeds. 2 

So far we have npt even mentioned the other points of 
support of the tensor palati muscle. First, its tendon is 
so firmly and strongly fastened to the hamular process 
that without previous loosening of this attachment, even 
powerful traction on the belly of the muscle fails to pro- 
duce the slightest motion in the soft palati. From this, 
it would seem as if we had here a very essential point of 
fixation for the operation of this muscle, which has not 
yet been at all sufficiently valued. We must here, also, 
take into consideration that part of the upper constrictor 
of the pharynx which, on account of its passing sidewards 
and forwards to the pterygoid process of the sphenoid 

1 Wiener Medicinalhalle, 1862, No. 18. 

2. Polifzcr, Wiener Medic. Wochenschrift, 1863, No. 6. 



MUSCLES OF THE EUSTACHIAN TUBE. I9I 

bone, has been called the pterygo-pharyngeus muscle. This 
muscle is inserted into the anterior and lower side of the 
hamular process, in such a way that it must be looked 
upon as an antagonist of the circumflexus muscle and its 
tendon, which is situated at the posterior and lower portion 
of the hamular process. 

This antagonistic relation of pterygo-pharyngeus to the circumflexus 
is especially marked in the horse ; for here the tendon of the former, 
like that of a pully-muscle, is perfectly movable where it winds round 
the hamular process. In the horse, both of these muscles might justly 
be considered as one muscle with two bellies — a tubal and a pharyn- 
geal belly — which lie in a rounded acute angle to each other; the 
angle being formed, i.e., fitted, by the pully of the hamular process. 
(See Archiv. fur Ohrenheilkunde, II, p. 218.) 

During contraction of this constrictor, the point of at- 
tachment of the circumflexus muscle to the hamular process 
must become the more fixed, and the development of its 
action in the direction towards the tube made the more 
easy. The salpingo-pharyngeal fascia is also inserted into 
this muscle, and it, as well as the lower portion of the 
membranous wall, can therefore be put upon the stretch 
by this muscle. 

Hence, there can be no doubt that during the act of 
deglutition the sphengo-salpino-staphylinus muscle finds a 
fixed point below ; that it draws the movable part of the 
tube outward and downward, and opens the tube. Politzer 
has, moreover, proved this influence of the muscle in 
question upon the tube, by experiments made in the Phy- 
siological Institute of this city. 1 As this muscle, on its 
other side, is surely not a " tensor of the soft palate," but 
only a cc tensor of the fibrous prolongation of the hard 
palate" (Henle), the name tensor palati should certainly be 

1 Ueber Eine Beziehung der Trigeminus zur Eustachian Ohrtrompete, Wurzburger Natur- 
wissenschaftliche Zeitschrift, 18 61, p. 94. 



I92 MUSCLES OF THE EUSTACHIAN TUBE. 

abandoned, and it, on account of its great importance for 
the tube, be termed the abductor or dilator of the tube ; for 
it must be regarded as an abductor of the lateral wall, and 
therefore as a dilator of the tube, and as an integrant part 
of the ear. 

Henkj in the first part of the second volume of his " Anatomisches 
Handbuch," absolutely denies that fibers of the circumflexus palati 
take their origin from the membranous tube, and consequently had to 
question all dilating influence of this muscle upon the tube. He even 
regarded it more probable that its fibers, during the moment of con- 
traction, press the wall of the tube towards the median line, and thus 
close the tube more firmly. In the third part of the same volume 
(1866, p. 755), he admits that it is this muscle which opens the tube 
with every act of swallowing ; but he still holds that only a few fibers 
of this muscle take their origin from the movable portion of the Eu- 
stachian tube. For he says : " A portion of the tendinous fibers 
(sehnige urspriinge) of the spheno-staphylinus muscle fuse with the 
firmer part of the lateral wall ; and in truth, these tendinous fibers 
press themselves through a thin layer, between the upper margin of 
the soft wall of the tube and the curved portion of the tubal cartilage, 
to become fused with the convex surface of the latter. By this adhe- 
sion to the cartilage of the tube, the spheno-staphylus muscle is enabled 
to unroll the upper rolled-up margin of the cartilage, and to enlarge 
the angle which the lateral forms with the median wall." Rildinger 
pronounces "the blunt extremity, of the hook cartilage, which is 
pointed downwards and inwards, to be the essential point of inser- 
tion of this muscle." He furthermore recognizes a connection be- 
tween the tendon of the muscle and the membranous wall of the 
tube (which he usually denotes "layer of fat," or "group of glands"). 
This, however, is not brought about by the attachment of tendinous 
fibers, but by bundles of connective tissue, the arrangement of which 
is such that they can be distinguished from the tendon. " During the 
contraction of this muscle, the hook-shaped portion of the cartilage 
is drawn downwards and somewhat sidewards ; and the movement of 
the hook-shaped cartilage must follow the membranous wall of the 
tube which is connected with it." 

It is interesting to notice that the muscle under consideration was, 
by its discoverer, Valsalva (1707), described under the name, "Novus 



MUSCLES OF THE EUSTACHIAN TUBE. 1 93 

Tubae Eustachianae Musculus ;" and he understood that it was a dilator 
of the tube, while more recent anatomists have considered it solely or 
mainly with respect to its importance to the palate. 

The second of the muscles to be considered here, the 
petro-salpingo-staphylinus, or levator palati mollis^ arises mainly 
from the under surface of the petrous portion of the tem- 
poral bone, very near the entrance of the carotid canal. 
This muscle lies in very close contact with the movable 
part of the cartilaginous portion of the tube ; but none of 
its fibers arise from any part of the same, although this is 
asserted by many authors. The roundish and cylindrical 
levator proceeds parallel with the tube, immediately 
under its floor or lower wall, and also slightly towards 
the middle. This wall consists usually of a very thin 
membranous tissue. Indeed, not unfrequently this mus- 
cle lies immediately beneath the mucous membrane, at the 
lower end of the opening of the tube. The salpingo- 
pharyngeal fascia passes between this and the previously 
described abductorof the tube ; the latter lies more outward 
(laterally) and upward ; the levator, on the other hand, 
more toward the middle and downward. 

This functional importance of this muscle, probably, 
chiefly concerns the palate, which, by the united action of 
both muscles, is lifted directly upward. With this, a 
narrowing of the pharyngeal orifice of the tube takes place ; 
the floor of the tube being pressed upward and outward 
by the muscle, as it increases in thickness during its con- 
traction. This constriction of the pharyngeal orifice may 
be observed by means of the rhinoscope. At the same 
time the entire configuration of the pharyngeal orifice 
undergoes an essential alteration ; its lower curved margin 
becoming more rectilinear or even arched in an upward 
and outward direction ; since the mouth of the tube, 
which was previously widely open and sloping downward, 
no longer falls off steeply toward the cavity of the mouth 

2 5 



194 MOVEMENTS OF MEMBRANA TYMPANI. 

and pharynx, it will, by the elevation of the velum 
palati, be doubly protected against all mechanical in- 
fluences coming from below, especially against articles of 
food and other foreign bodies which, during vomiting 
or sneezing, occasionally find their way into the upper 
part of the pharynx. It cannot be stated with precision 
in how far contraction of this muscle exerts a positive 
influence upon the caliber of the canal in the remaining 
portion of the tube ; but as the fascia which borders it 
might be stretched outward, and the floor of the tube be 
crowded upward by its swelling, it might, by drawing the 
membranous wall of the tube sideward, be enabled to assist 
in producing gaping of at least the lower part of the tubal 
opening. 

According to A. Luces and Schwartze (Archiv. fur Ohrenheil- 
kunde, I, S. 96, u. S. 139), simple respiratory movements will, in 
many cases of a normally pervious Eustachian tube, be sufficient to 
produce a manometrically provable change of air in the cavity of the 
tympanum, and this usually produces visible movements in the mem- 
brana tympani. Luces' s sterling and thorough observations, which 
were made on patients, and also on numerous individuals with normal 
ears, proved that there existed a constant relation between these 
processes in the cavity of the tympanum on the one hand, and the 
movements of the soft palate, and the faucial orifice of the tube during 
inspiration, on the other. With the inspiration there showed itself, 
in the patient first examined, besides the moving outward of the 
drum, a regularly occurring, vigorous elevation of the velum palati, 
and at the same time a distinct constriction of the pharyngeal orifice. 
As the mouth of the tube was obstructed by mucus, from a severe 
catarrh of the pharynx, no more movements of the drum took 
place during respiration, although the movements of the soft palate 
were normal. If it were proven that the levator palati, like the true 
abductor tubae, were capable of opening the tube, which I think alto- 
gether probable, Luces' s observations might, most readily, be refer- 
red to the activity of this muscle. Attention must also be called 
to the fact that this muscle is supplied by the pneumo gastric, and 
that so far as its nerve supply is concerned, it is certainly in direct 



VESSELS AND NERVES OF THE MIDDLE EAR. 1 95 

relation with the » respiratory system. Politzer 1 is of opinion that, 
ordinarily, during respiration, the tube does not become open, and 
that no movement takes place in the normal drum. Considering the 
importance of this question, further thorough examinations, especially 
on individuals with sound ears, are exceedingly desirable. Luces in- 
dicates its great practical importance by saying : " It is not improbable 
that all diseases, which in any way disturb the respiratory function, also 
indirectly more or less impede the respiratory act of the ear, and 
thereby, perhaps, aid in the production of certain diseases of the organ." 

In his most recent publication on this subject, Lucte maintains his 
view as to the permeability of the tube in simple respiration, and sup- 
ports it by numerous new examinations on persons with normal 
hearing power. He also shows, in the oblique position of the tube, 
and the position of the membranous wall below, and externally, that 
the latter must necessarily, by the weight of the muscle arising from 
it, and the soft palate, be drawn away. 

I may also mention a fact, which is as yet unexplainable to me. 
In cases where, during the existence of catarrh of the pharynx, all 
attempts at Valsalva's experiment, even when very forcibly and fre- 
quently made, are attended with failure, and in which we must there- 
fore assume that the walls of the tube are firmly pasted together by 
very tenacious mucus, simple ructus — air belched from the stomach — 
will at the same time often enter the ear with unusual force. 

Vessels and Nerves of the Middle Ear. — The cavity of 
the tympanum receives its supply of nutriment from very 
different sources. One of these is the stylo-mastoid branch 
of the posterior auricular artery (external carotid), which, 
in its course through the Fallopian canal, also gives off 
branches to the coverings of the facial nerve, to the stape- 
dius muscle, and at the same time supplies the cells of the 
mastoid process. The ascending pharyngeal artery (from 
the external carotid) supplies the lining membrane of the 
cavity of the tympanum, the mucous membrane of the 
Eustachian tube, and the tensor tympani muscle. The 

1 Beluchtungstilder des Trommelfells, S. 139. This work has been translated by Drs. 
Mathewson and Newton of Brooklyn, and will soon be published. — St. J. R. 



I96 VESSELS AND NERVES OF THE MIDDLE EAR. 

middle meningeal artery (maxillary internal) which, as is 
well known, supplies the greater part of the dura mater, 
sends branches to the cavity of the tympanum as well as to 
the Eustachian tube ; they enter through the hiatus canalis 
Fallopii and the petro-squamosal fissure. Lastly, one or 
two branches are given off from the internal carotid, as it 
passes through the petrous bone, which enter from the 
carotid canal, and are distributed to the cavity of the tym- 
panum and the Eustachian tube. 

The nerves of the middle ear are derived from the tri- 
geminus, the facial, the glosso-pharyngeal, the vagus, and 
from the great sympathetic. The otic ganglion and the 
chorda tympani also supply this cavity. 

The tensor tympani receives a small branch from the 
motor internal pterygoid nerve, which is itself a branch of 
the third division of the trifacial. It also receives a fila- 
ment from the otic ganglion. According to Luscbka, 1 the 
former presides over the voluntary, and the latter the in- 
voluntary tension of the membrana tympani. It is said 
that the voluntary activity of the tensor tympani is always 
accompanied by movements of the soft palate, which also 
receive branches from the internal pterygoid ; and Luscbka 
is of opinion that the opening of the mouth in listening 
is associated with a simultaneous tension of the velum 
palati, and that it by no means proceeds from a widening 
of the auditory canal, due to depression of lower jaw. 
This same internal pterygoid also sends a motor branch to 
to the spheno-salpino-staphylinus muscle (our abductor 
tubas). Lastly, the pharyngeal orifice of the tube receives 
branches from the superior pharyngeal of the second di- 
vision of the fifth nerve. The facial sends a small branch 
to the stapedius muscle. 2 

1 " Uber die Willkurliche Bewegung des Trommelfells." Archiv. fur Physiolog Heil- 
kunde, 1850, IX, B., S. 80-85. 

[< Politzer proved the innervation of the two inner muscles of the middle ear by experi- 
ments. Wiener Medizinische Wochenschrift, 1861, Nos. 41 and 42. 



VESSELS AND NERVES OF THE MIDDLE EAR. 1 97 

The nerves of the mucous membrane of the cavity of the 
tympanum, and Eustachian tube are derived from the 
glosso-pharyngeal, whose tympanic branch (or Jacobson's 
nerve) penetrates the floor, and ascends the promontory. 1 
Finally, the vagus sends a branch to the levator palati 
mollis, which we must regard as a muscle of the tube, and 
which therefore belongs to the ear. 

All authors state that the great sympathetic furnishes 
branches to the cavity of the tympanum, but they differ 
as to the manner in which this is done. Hyrtl describes a 
tympanic plexus, which little net consists of a combination 
of the great sympathetic, the trifacial, and the glosso- 
pharyngeal. It is situated on the floor and the anterior 
part of the wall of the labyrinth, and supplies the lining 
membrane of the entire middle ear — the cavity of the 
tympanum, the mastoid cells, and the Eustachian tube. 
According to W. Krause, the highly nervous mucous 
membrane of the Eustachian tube does not only receive 
microscopic branches from this tympanic plexus, but a 
larger branch may be traced to the cartilaginous tube. 

It may be mentioned here that F. Arnold 7 - has described two recur- 
rent branches of the trifacial, which pass along the bony surface of the 
middle cerebral fossa, and a recurrent branch of the pneumo-gastric, 
which proceed to the transverse sinus and to the posterior cerebral fossa. 2. 

In reference to the origin of the nerves composing the 
tympanic plexus, we have to distinguish : 

1. Several nervi carotico-tympanci, branches from the 
plexus of the sympathetic in the carotid canal, which enter 
the cavity of the tympanum through special foramina. 

2. A twig of the superficial petrosal nerve, entering the 
cavity from above, being a connection between the otic 

1 According to W. Krause (Zeitschrift fur ration. Medizin, 1866, B. XXIII, S. 92), gang- 
lion cells are imbedded in various parts of the tympanic nerve. 

2 Zeitschrift der Ges. der Weiner Aerzte, 18 61. 



I98 VESSELS AND NERVES OF THE MIDDLE EAR. 

ganglion and the bend of the facial, but which, according 
to other authors, is to be regarded a continuation of the 
tympanic (Jacobson's nerve) to the otic ganglion. 

3. The ramifications of the tympanic from the glosso- 
pharyngeal. 

The otic ganglion, or Arnold's ganglion, is certainly of 
the same importance to the organ of hearing as the ciliary 
ganglion is to the eye ; but physiology has, as yet, paid but 
little attention to it. It is situated near the foramen ovale 
of the greater wing of the sphenoid bone, in front of the 
middle meningeal artery, on the outer side of the cartilagi- 
nous portion of the Eustachian tube and the point of origin 
of the tensor tympani. It is composed of motor fibers 
from the third division of the fifth nerve, of sensitive fibers 
from the glosso-pharyngeal, and of fibers from the great 
sympathetic. The otic ganglion sends the before men- 
tioned little branch to the tensor tympani, which governs 
its reflex activity. It sends a twig to the external pterygoid 
branch of the trigeminus, and several branches of commu- 
nication to the nerve auriculari of the third division of 
the fifth, which, as we have seen, supplies the integument 
of the external auditory canal and the membrana tympani. 
By means of this ganglion, the soft palate, the drum with 
its tensor muscle, the lining membrane of the cavity of 
the tympanum, and the integument of the external ear, 
are put in sympathetic relation with each other, and with 
the nervous system generally. 

The chorda tympani of the facial, though it passes along 
the outer wall of the cavity of the tympanum, does not, 
according to the statements of most reliable investigators, 
send a branch to this cavity, and appears, therefore, to be 
in no physiological relation with it. 



LECTURE XIII. 

CATHETERIZATION OF THE EUSTACHIAN TUBE. 

The history of the subject ; common errors in the use of the 
catheter; method of introduction; accidents which may occur ; 
spasm of the oesophagus ; emphysema ; hemorrhage ; descrip- 
tion of the catheter. 

Gentlemen : Now that we have studied the anatomy 
of the middle ear, we may turn our attention to the diseases 
which may arise in this part of the organ of hearing. In 
order to act directly upon the cavity of the tympanum, in 
its deeply situated position, we must make an approach 
from without ; in other words, we must elongate the ex- 
ternal opening of the Eustachian tube. Otherwise, we 
shall not be able to perfectly recognize the abnormal con- 
ditions of this part of the ear ; and still less can we treat 
its affections directly and locally. 

For the purpose of reaching the middle part of the ear, 
we introduce a tube into the pharyngeal orifice of the Eu- 
stachian canal. This instrument is called an ear, or Eusta- 
chian catheter. It now becomes our task to examine into 
the method of employing this instrument. We shall also 
study its practical value, and investigate the appliances 
and instruments which may assist us in its useful employ- 
ment. 

It was an extremely long time before physicians recog- 
nized the fact, that there was any sort of practical and 
therapeutical use to be made of the passage connecting the 
ear and the throat. The existence of the Eustachian tube 



200 CATHETERIZATION OF EUSTACHIAN TUBE. 

was certainly known to Aristotle. It was first examined 
and exactly described by Bartholomeus Eustachius in 1562. 1 
But more than a hundred and fifty years passed before a 
layman made the first attempt to introduce an instrument 
into the Eustachian tube. As is well known, Guyot, the 
post-master of Versailles, in 1724, proposed to the Paris 
Academy to inject the Eustachian tube through a curved 
tin tube, introduced through the mouth. He is said to 
have in this manner relieved himself of deafness, which had 
existed for a long time. A surgeon in the English army, 
Archibald Cleland^ in 1741, without seeming to know any- 
thing of Guy of s method, proposed to introduce a tube 
through the nostril. This method is the only one that is 
practicable, and still employed. 

Any one who wishes to be able to diagnosticate and treat 
diseases of the ear, must be able to use the Eustachian 
catheter. We are constantly required to use it in practice, 
and in many cases it can be by no means fully replaced. 
You will find a general conviction among surgeons, that 
the introduction of the Eustachian catheter is a very diffi- 
cult, as well as a painful operation. You, however, have 
seen that such is not generally the case ; and that it is only 
true in exceptional and rare instances. On the contrary, 
this operation, in by far the greater number of cases, is an 
easy and painless one, if we but understand the anatomy 
of the parts, and the method of performing it. To illus- 
trate this it may be noticed that JVendt, in Leipzig, allows 
his pupils, after they have had a little practice, to introduce 
the instrument upon himself. Practice will soon overcome 

1 The words of Eustachius, on his " Epistola de Auditus Organis," where he describes this 
passage, which still bears his name, have no foreboding in them, that his discovery would 
remain so long unused : " Erit etiam medicis hugus meatus cognitio ad rectum medicamentorum 
usum maxime uti/is, quod sclent posthac ab Auribus, nom angustis foraminibus, sed amplissima 
'via posse materias, etiam crassoas, vcl a naturae expelli •vel Medicamentorum ope commode 
expurgari." Bart h Eustachii opuscula Anatomica. Delphis, 1 726, p. 140. Appeared at 
first in Venice, 1563. 






CATHETERIZATION OF EUSTACHIAN TUBE. 201 



all the little difficulties in the way of an Fig. 17. 
easy introduction of the catheter. 

I use a silver catheter, bulbous-shaped at 
its curved end, with a ring on the side of its 
funnel-shaped extremity. This ring shows 
us, by its position, the exact situation of 
the point of the instrument. We should 
always, during the introduction of the in- 
strument, keep a finger upon the ring, in 
order that the direction of the beak may be 
clear to us, and in order that we may readily 
turn it. Oiling the instrument before intro- 
duction seems to me unnecessary. It is 
well to cause the patient to blow his nose 
before the operation, in order that slight 
temporary obstructions may be removed, 
and the canal somewhat moistened. I will 
now go over all the steps of the operation, 
as I have already done on a half head of a 
cadaver, and upon some of you yourselves. 
We introduce the bulbous-shaped, curved 
extremity of the catheter, with the point 
directed a little downward, into the inferior 
meatus of the nose, then quickly raise the 
whole instrument, so that the ring shall be 
exactly on a vertical line, and push it care- 
fully further in, hugging the floor of the 
nasal cavity, till the posterior wall of the 
pharynx be reached, where we touch the 
atlas and basilar portion of the occipital 
bone. Then the catheter is drawn from 
one-third to three-fourths inch backward, 
toward the operator ; the outer end is 
somewhat elevated, and the ring, which has 
hitherto been on a vertical line, is turned 
to one running upward, and outward or 

26 

Eustachian Catheter. 



202 CATHETERIZATION OF EUSTACHIAN TUBE. 

opposite to the external ear. In some rare cases, the ring 
can only be made to lie horizontally. This is more apt 
to be the case in children than in adults. It is well to 
support the head of the patient during the operation by a 
hand passed around the back of the head. Both surgeon 
and patient may stand, or both sit, while the catheter is 
being introduced. (I find it much more convenient for 
the patient to sit, while the surgeon stands, in the per- 
formance of the operation. St. J. R.) 

The above described method is the one given by Kra- 
mer, and is undoubtedly the best. It has been advised 
not to pass the instrument as far back as the wall of the 
pharynx, but to first attempt to turn the point of the 
instrument into the mouth of the canal, which is situated 
somewhat anterior. This method seems quicker and more 
convenient, because we are not obliged to pass over the 
same way twice. But it is, after all, a much less certain 
method, because the surgeon is not generally able to tell 
at what instant the instrument leaves the inferior nasal 
meatus, and enters the naso-pharyngeal space. It is much 
easier to know just where the instrument is, if we proceed 
as above described ; that is, if we first introduce it to the 
posterior wall of the pharynx, and then withdraw it a por- 
tion of the way. 

Let us now examine the various steps of the manipula- 
tion a little more exactly, and at the same time mention 
the most frequent errors, as well as some difficulties that 
may occur. 

In the first place, in the introduction of the catheter, 
we should avoid delaying on the nasal meatus, or push- 
ing the instrument about in that locality, for the part 
is very sensitive and ticklish. In many cases it is well to 
draw the upper lip down, with a finger of the other hand, 
and thus render the nasal meatus more permeable. In 
some narrow, fissure-like nasal passages, the introduction 



CATHETERIZATION OF EUSTACHIAN TUBE. 203 

will be made easier by drawing the ala of the nose to one 
side. The beginner should place his patient opposite a 
window, in order to illuminate the parts well. 

As soon as the instrument has entered the meatus, the 
catheter should be changed from its oblique or vertical 
position to one that is horizontal, and then be kept 
quickly but firmly in this latter one, hugging the floor of 
the meatus till the posterior wall of the pharynx is reached. 
If we do not observe this precaution, there is danger of 
passing the instrument into the middle meatus of the nose, 
the passage of which is painful, and from which it is often 
impossible to turn the beak into the mouth of the tube. 
The lower nasal meatus and the floor of the passage are 
much less sensitive than the middle passage. The latter 
*lone is adapted for the passage of the catheter. 

It is only in rare cases that there is any danger after the 
instrument has entered the inferior meatus, of passing from 
it into the middle one. When the inferior turbinated bone 
is small, and the lower meatus very narrow, this accident 
may sometimes occur, but it is always to be avoided by 
following the rule given above ; that is, to hug the floor of 
the meatus with the beak of the instrument. If the catheter 
has been introduced through the inferior meatus, it always 
stands nearly at a right angle to the surface of the face. 
If it has entered the middle one — a not unfrequent error — 
it will be in an oblique position, and will form an acute 
angle to the facial plane. 

As a rule, the beak of the catheter should be directed 
downward in passing through the nostril. If we find any 
difficulties in introducing the instrument in this manner, 
we should try to avoid them by lateral movements of the 
catheter. Such lateral movements should at first always be 
made with the beak outward, and at the same time the 
extremity of the instrument should be held with a delicate 
but firmer hand in the tips of the fingers. 



204 CATHETERIZATION OF EUSTACHIAN TUBE. 

I have not un frequently met with cases, where, in order 
to obviate the difficulties from irregularities in the nasal 
canal, I have been obliged to turn the catheter completely 
on its axis, as we are often compelled to do in catheterization 
of the urethra. The manipulation is there known, as le tour 
du maitre. If we do not succeed in entering the mouth of 
the tube by these manipulations, we should take another 
catheter, one that has a different curvature, or that is of a 
smaller caliber. I have found these difficulties in catheter- 
ization somewhat more frequently on the left side than on 
the right ; hence, I would advise that you always begin with 
the right nostril, in examining patients. On examining a 
number of macerated skulls, I find that the bony wall, 
which seldom stands exactly on the median line, is oftener 
deviated to the left than the right. Sometimes the whole 
of the former stands in an oblique position, while again 
only a portion of its surface is bulged out. There is also a 
great variety in the conformation and development of the 
inferior turbinated bone. Added to these deviations from 
a strictly normal condition, the outer part of the nose, in 
most persons, is placed a little obliquely toward the left. 
The most common mistake in the introduction of the in- 
strument is, that it is not withdrawn far enough after it 
has reached the posterior wall of the pharynx. The beak 
thus falls into the little fossa, called Rosenmiiller's fossa, 
situated behind the mouth of the Eustachian tube. We 
may make this mistake by half unconsciously pushing the 
instrument backward in turning it. This mistake is the less 
remarked, because in gently withdrawing the catheter from 
this position, there is about the same sensation of resistance 
as when it is in the mouth of the tube itself. If we blow 
through the catheter when it is in this position the air is felt, 
not in the ear, but in the neck, and we have a moist, flutter- 
ing sound, as if mucus collected there had been set in motion. 
Benjamin Bell, the distinguished Edinburgh surgeon, says 



CATHETERIZATION OF EUSTACHIAN TUBE. 205 

that when aurists claim to have entered the entrance of the 
Eustachian canal, they have only entered this fossa. This 
statement, of course, proves nothing more that that great 
men sometimes make great mistakes. It is true that this 
error of lodging the instrument in this fossa is a mistake 
often made, and not always by beginners alone, but by 
those who have had great experience with the catheter. 
This may be explained by the fact, that there is no rule, 
as to just how far we shall withdraw the point of the instru- 
ment, after having reached the posterior wall of the pharynx, 
since the distance of the mouth of the tube from the ver- 
tebrae is different in different individuals. 

Tortual^ in his " Untersuchungen liber den Bau der Menschlichen 
Schlund and Kehlkopfes," Leipzig, 1846, states — basing his opinion 
on a great number of measurements of the skulls of men and animals — 
that there is always a certain proportion, in fully grown persons, be- 
tween the depth of the head of the pharynx (Schlund Kopf) and the 
hight of the semi-circular lateral surface of the skull, that is, the point 
of origin and development of the temporal muscles. It is conceivable 
that, from this proposition, conclusions could be formed, by an ex- 
amination on the living subject, of the distance of the mouth of the 
tube from the posterior wall of the pharynx. Man is distinguished 
from the other mammalia by having the least depth of pharynx and 
the slightest development of the temporal muscles. Men of an ani- 
mal organization, with very large masticating and deglutory muscles, 
have also a great depth of the pharynx. 

Beginners are more apt to turn the beak too late than 
too early. After some practice, however, we become cer- 
tain in the use of the instrument. The introduction of 
the instrument into the mouth of the canal, in the case of 
children, is difficult, especially if the mucous membrane is 
swollen and puffy. The pharyngeal orifice of the tube in 
children is not so far forward in the pharynx as in adults ; 
and the small undeveloped lips of the opening lie so far 
I apart that we often have trouble, even on the cadaver of 
an infant, in placing the instrument in the proper opening. 



2o6 CATHETERIZATION OF EUSTACHIAN TUBE. 

Occasionally, although rarely, after we have had some 
practice with the instrument, a case occurs where one side 
of the nose is impassable. This may occur in consequence 
of abnormal narrowing of the inferior meatus, as well as 
from nasal polypi and granulations, or swellings on the 
inferior turbinated bone, from which bleeding readily oc- 
curs, and also in consequence of a particularly oblique 
position of the nasal septum. 

Thus, I have several times found the cartilaginous septum 
bulged out to one side, to such an extent that the meatus 
could scarcely be entered with a probe. I once found the 
inferior nasal meatus of one side nearly impermeable in 
consequence of an abscess of the gum. This was a case 
where a catheter had been regularly introduced for several 
weeks without any difficulty or pain. In some cases 
impermeability of the meatus may be due to former injury 
of the nose, to which, in the period of childhood, we are 
especially exposed. (As an instance of the frequency of 
the cases in which an impermeability of one nasal meatus 
exists, I may state, in confirmation of the author's views, 
that while writing the very lines above, I was called on by 
a patient in whom the left nasal passage was impervious 
to even the smallest catheter, in consequence of an injury 
done to the nose from a ball thrown by a play-fellow. St. 

J-R-) 

Any abnormities which are more deeply situated than 
the above, may be brought to view by placing a larger 
aural speculum, or Kramer's dilating speculum, in the nose, 
at the same time illuminating the parts with the mirror. 
In other cases, an examination of the naso-pharyngeal 
space with the rhinoscope will determine the nature of the 
obstruction. 

In the comparatively rare cases where one nasal meatus 
is impermeable, we may generally introduce the catheter 



CATHETERIZATION OF EUSTACHIAN TUBE. 207 

from the other meatus, an operation that has been im- 
properly pronounced by some to be impossible. I do not 
use any especial instrument for this, except a catheter with 
a long beak, and of greater curvature than is otherwise 
necessary. Of course, we cannot as readily and certainly 
find the mouth of the tube from the opposite side. The 
catheter is easily displaced, the current of air is not so 
powerful, and a rattling sound is heard in the throat; but 
in case of necessity we may adopt this method. Of course, 
practice with the instrument makes the cases, where it can- 
not be introduce without difficulty, always rarer. As a 
last resort, in cases of failure to pass through the nostril, 
we may attempt to introduce the catheter through the 
mouth, as Guyot proposed. During rhinoscopy, it would 
not be difficult to introduce a properly curved instrument, 
e. g., a caustic holder, into the mouth of the tube, through 
the mouth ; and the introduction of a catheter of similar 
curvature would not be difficult. 1 

Once more then, gentlemen, catheterization of the ear 
is by no means difficult. Every physician will soon ac- 
complish it with ease, if he will but take the trouble to 
learn the necessary steps of the operation. The reason for 
the opposite opinion, which has been so widely embraced 
by the profession, depends upon the belief that in this 
case the prerequisites to success in any other operation, i. e., 
a careful study of the parts involved, and practice on the 
cadaver, may be neglected. 

After having studied the parts in a half head, and prac- 
ticed the introduction of the catheter upon this, you may 
proceed to introduce it in the head of a subject which has 
not been divided. The position of the catheter may be 
ascertained and regulated by passing the finger behind the 
soft palate through the mouth. After all this has been 

1 Lowenberg, Archiv. fur Ohrenheilkunde, II, S. 12. 



208 CATHETERIZATION OF EUSTACHIAN TUBE. 

passed through, we should practice the introduction of the 
instrument on ourselves. 

The correct position of the instrument may be known 
by the following named conditions : In speaking and 
swallowing it remains immovable. The beak cannot be 
turned any farther upward, and the air that is blown in, is 
felt in the ear, or at least toward or against it. For the 
purpose of forcing in the air, a gutta percha air bag may 
be used, or the air may be blown in through a gutta percha 
tube, with a nozzle on each end ; one of which is placed 
in the mouth of the surgeon, and the other in the funnel- 
shaped extremity of the catheter. 

Fig. i 8. 




Gutta Percha Air Bag. 

I cannot sufficiently recommend practice with the catheter 
on yourselves. To the physician, who in his avocation is 
so much exposed to colds, occasion is very often furnished 
to employ this instrument for its appropriate use ; that 
is, for the purpose of retaining his hearing power. 

When the catheter is properly introduced it causes no 
pain. The majority of patients speak only of an unplea- 
sant sensation, of a tickling in the throat, while the ope- 
ration is being performed for the first time. On repetition 
of the operation all these unpleasant feelings disappear. 
They occur at the first time, because we are dealing with 
parts that are scarcely ever touched. When there are 
natural hindrances to the passage of the instrument, 
abnormal narrowness of the canal, &c, the operation 
cannot be performed without pain ; but these are excep- 
tions. More inconvenience is caused when the instrument 



CATHETERIZATION OF EUSTACHIAN TUBE. 209 

is introduced with uncertainty and want of skill, and the 
mouth of the tube is not readily found. Although we 
very often find catarrh of the cavity of the tympanum 
connected with catarrh of the pharynx, the unpleasant 
sensation in the nose and pharynx scarcely ever amounts 
to pain ; and it is only in cases of great irritation that fits 
of coughing occur. The sensitive membrane soon becomes 
accustomed to contact with the instrument, and we can 
soon pass from a slender and slightly curved one to a 
larger. 

Sometimes it happens, especially at the first trial, in 
very sensitive and anxious patients, that a spasm of the 
muscles of the pharynx and palate occurs, and the instru- 
ment, if not already in the mouth of the tube, is held fast, 
and prevented from any further motion, while, from the 
severe pressure on the mucous membrane, severe pain is 
caused. The surgeon should then endeavor to quiet the 
patient, endeavor to induce him to open the spasmodic- 
ally closed eyes, and look calmly about, while he lightly 
turns the catheter into the proper position. The patient 
must neither speak nor swallow before the instrument is in 
the entrance of the Eustachian tube. The quieter and 
more confiding the patient, so much the easier is the oper- 
ation for the surgeon. The more decided the surgeon is 
in his manner, the less time he wastes in telling what is 
about to be done; the easier, especially with nervous 
patients, will the operation be performed. 

As to other accidents that may occur, besides the spasm 
just spoken of, we may first speak of emphysema of the 
neck, which has been very much feared, occasioned by air 
passing through a perforation of the mucous membrane. 
In the greater number of instances the emphysema oc- 
curred where the catheter had been often introduced, and 
where no unpleasant symptoms had previously occurred. 

On the cadaver we quite often find erosions, and trifling 
27 



210 CATHETERIZATION OF EUSTACHIAN TUBE. 

ulcerations about the mouth of the tube. These are not 
to be diagnosticated without the rhinoscope, and may easily- 
lead to emphysema. It is very evident that any want of 
delicacy of contact with such an already abnormal mucous 
membrane may easily produce its rupture. It is also 
well not to give the ear an air bath immediately after the 
introduction of catgut bougies into the tube, for the 
membrane may be easily ruptured by them. These air 
tumors of the neck affect the swallowing, and alarm the 
patient. In the most cases all the symptoms disappear in 
the course of a day. I saw one case, however, where the 
emphysema produced difficulty in swallowing that lasted 
for five days. One of the patients very naively remarked, 
that his neck felt like veal that had been blown up by the 
butcher. It will be best to divide one of the vesicles on 
the uvula with the scissors or knife, should the emphysema 
occur, and thus give an exit to the air, and immediate 
relief to the patient. c Turnbull i of London, is said to have 
lost two patients, some twenty years ago, from the use of 
the Eustachian catheter. Even if the compression pump 
were too strongly filled (he had intrusted the filling to the 
patient), it is hard to see, from the published account of 
the autopsy, how the accident occurred. 1 (It is said that 
Turnbull used a long instrument, and that he caused it to 
produce a rupture of the laryngeal mucous membrane. 
St. J. R.) 

We know how common a thing is hemorrhage from the 
nose, and that in some people it is induced simply by a 
severe fit of sneezing. We need not be surprised, then, 
that the catheter is sometimes tinged with blood, or that 
slight hemorrhage occurs, when not the slightest pain or 
inconvenience has been caused. If such bleedings return 
or continue, a solution of alum, gr. ij ad aqua 3i, may be 
snuffed up the nose, and this will probably soon check the 

i See M. Frank's Handbuch der Ohrenheilkunde, S. 173. 



CATHETERIZATION OF EUSTACHIAN TUBE. 211 

bleeding. The irritation of the nasal mucous membrane, 
caused by the catheter, often produces an increased secre- 
tion of tears, which run over the cheeks, when not the 
slightest pain has been caused. 

It is necessary to have several instruments in order to 
be successful in the introduction in all cases. It has been 
very much insisted upon, that the instruments should be 
of different caliber. According to my idea, it is much 
more important that they should be differently formed as 
to the length and curvature of the beak. 

These latter named variations are most important with 
respect to the varying breadth and hight of the inferior 
nasal meatus, and as regards the distance between the pos- 
terior end of the nasal septum and the mouth of the tube, 
which varies very much in different persons. 

The catheters which I generally use measure 3 mm. in 
caliber; at the beak, 4 mm. I use one smaller when the 
nasal meatus is very narrow, or in the case of children ; its 
caliber is then from 2 mm. to 3 mm. The accompanying 
sketch represents the largest instrument. Three of differ- 
ent sizes are sufficient for all cases. We may give the 
catheter any curvature we wish, having first taken the 
precaution to draw a wire through it. (This presupposes 
that the instruments are made of pure silver. My experi- 
ence causes me to use only instruments made of alloyed 
silver, where no bending is allowed. Otherwise they are 
apt to bend, when yielding is not desired. St. J. R.) 

The effect is always more powerful, when a catheter 
with a large curve, and of quite large caliber, is employed. 
It is also well, during the blowing in of air, to press the 
catheter somewhat on the nasal septum, which enables 
it to enter the mouth of the Eustachian tube more 
deeply. The more the point of the instrument is enclosed 
by the walls of the tube, of course the greater the effect 
through the catheter. In some cases, the current of air 



212 CATHETERIZATION OF EUSTACHIAN TUBE. 

enters the ear most powerfully, when, without displacing 
the catheter, it is drawn from its original position in the 
mouth of the tube slightly forward toward the operator. 
By no means unfrequently two sorts of catheters are neces- 
sary for the two sides, in one patient. 

Elastic catheters are much less to be recommended than 
silver ones. We cannot have as certain a touch with a 
flexible instrument. If, perhaps, we pass through the nasal 
meatus more easily, it is more difficult to find the mouth 
of the tube with them. Comparative experiments have 
also shown that the stream of air through an elastic 
catheter is not so strong upon the ear as that from an 
instrument made of unyielding material. 

This may depend from the fact that we are not so cer- 
tain of pressing upon the lowest portion of the tube with 
a flexible, as with a firm instrument. Besides, silver 
tubes, as a rule, can be easily introduced and without pain. 
I prefer them to the hard rubber ones very recently recom- 
mended by Politzer. 

It is necessary that a surgeon who has many aural pa- 
tients should have a large number of catheters, in order 
that he may not be compelled to use the same instrument 
on different persons before it has been thoroughly washed 
with hot water. Syphilis has been several times transmit- 
ted, especially in Paris, through the Eustachian catheter. 
I would also advise you to blow through a catheter before 
introducing it into the tube. 



LECTURE XIV. 

THE PRACTICAL VALUE OF CATHETERIZATION OF THE EAR. 

Diagnostic value; auscultation of the ear; the otoscope and air 
bath; manifold use of the catheter in the treatment of dis- 
eases of the ear; effect of the air bath; the catheter as a 
vehicle for introducing gaseous and solid substances into the 
middle ear; rubber air bag; compression pump ; instrument 
for holding the catheter in position. 

Gentlemen: After having learned the mode of intro- 
ducing the Eustachian catheter, the question occurs — what 
is the practical value of catheterization of the ear, and in 
what cases may we employ it? A general answer may be 
made as follows; Its use is so to open the Eustachian 
canal and cavity of the middle ear in order that we may 
produce a direct effect upon them by remedial agents. It 
is not possible to do this by other means, except when 
there is a loss of substance in the membrana tympani, and 
thus the middle ear is in part exposed. 

The Eustachian catheter is only a means of introduc- 
ing agents into the cavity of the tympanum. It, of itself, 
will accomplish nothing, although some medical men, who 
content themselves with introducing it into the nose and 
pharynx, or even the mouth of the tube, and who then 
immediately withdraw it, seem to believe that it has some 
specific virtue of itself. By the mere introduction of the 
instrument, at the most, some mucus may be removed 
from these parts, or the walls of the lowest portions of 



214 AUSCULTATION OF THE EAR. 

the tube be somewhat pressed apart. This, however, as a 
rule, accomplishes very little. 1 

The effects of the catheter upon the middle ear have a 
relation to the diagnosis, as well as the treatment, of dis- 
eases of the ear. We must therefore consider catheter- 
ization from these two points of view. 

Let us first speak of auscultation of the ear. Laen- 
nec described this in his treatise on the general subject of 
auscultation, 4 where he devotes an entire section to the 
special theme. Auscultation of the ear allows us to form 
some conclusions as to the condition of the tube, as well 
as of the cavity of the tympanum. 

Physicians generally assert that the ear is inaccessible in 
a diagnostic as well as a therapeutic respect. It is only 
true, however, that in some respects it is less accessible 
than some other organs. When we desire to auscultate 
the lungs or heart, we simply place our ear upon the chest 
of the patient, either directly or by means of a stetho- 
scope, and in this manner we may listen to the various 
sounds. In auscultating the ear, the matter is not quite 
^.so simple. Here we need for the same purpose both 
skill and a certain apparatus. We must first introduce 
the catheter into the mouth of the tube, and then produce 
an artificial current of air, in order to form our deduc- 
tions. For this latter purpose we may blow the air from 
our own lungs through the mouth, or by means of an 
india-rubber air bag. We may also induce the current 
from a compression pump, gasometer, or the like. The 
sounds thus excited in the ear, the surgeon may hear by 
placing his ear directly upon that of the patient, or more 



i PAilapeauXy of Lyons, employs such a method. He passes a probe with an olive 
shaped beak through the nose, and introduces it as far as possible into the tube, about I to 
2 1-2 in. Du cath6Urisme de la trompe cP Eustache a Paid6 bes cathitcrs a boule. Lyon, 
1859. 

* Traite de l'auscultation mediate. Paris, 1837. 4 edition T. in, p. 535. 



TOYNBEE S DIAGNOSTIC TUBE. 



215 



conveniently by means of a stethescope adapted for this 
purpose. 

Toynbee, in 1853, suggested the use of an elastic tube 
with two tips, with which to auscultate the sounds pro- 
duced, in the ear, when a motion of swallowing is made, 
with the mouth and nose closed. He called this tube, the 
otoscope. The name is a very good one, as well as 
the instrument. We retain both, but we enlarge the 
applicability of the latter. 

Fig. 19. 




Otoscope or diagnostic tube, 

(It may be suggested that the name otoscope is better 
adapted to the mirror for examining the membrana tym- 
pani, just as the one for examining the throat is called 
the laryngoscope, that for the eye, the opthalmoscope, etc. 
It is better to call the so-called otoscope a diagnostic tube, 
as Kramer suggests. St. J. R.) 

If a powerful stream of air pass through an Eustachian 
tube of normal size and having a normal degree of moisture, 
it creates a sound which Delau likens to the falling of rain 
upon the leaves of a tree, and therefore calls " bruit de 
plaie." I would rather call it a vesicular murmur, or if the 
\ force of the air be very great, a knocking sound (anschlage 
gerausch), because we hear the stream of air striking a dry, 



21 6 AUSCULTATION OF THE EAR. 

elastic membrane — the drum — and pushing this somewhat 
outward. The sound passes through the otoscope, or tube, 
and seems to the examiner to be very near him. The patient 
will exclaim that the air is passing through the ear, whereas 
it has only entered it. If the mucous membrane be 
smeared with the normal secretion, the sharpness of tone is 
somewhat mollified — it becomes soft, not to say moist. 
Sometimes this knocking or rapping sound seems very 
hard and dry. It is then usually accompanied by a pe- 
culiar dryness of the mucous membrane. We then may 
conclude that there is a want of mucous secretion, such as 
is often found after an inflammatory process has been going 
on, and also in old people. It may also be often accom- 
panied by great permeability of the tube. If the mem- 
brana tympani has been very much thickened, or is very 
much sunken, this knocking sound is particularly marked. 
If the Eustachian tube has been obstructed through swell- 
ing of its membrane, the air enters, instead of in a full, 
strong stream, in a thin, weak and interrupted one, and 
often with a whistling sound, striking most strongly 
on the membrana tympani when the patient swallows. 
Frequently we hear the air enter only during the act of 
swallowing. 

In these cases, when not swallowing, the patient does 
not feel the air in the ear, but towards it, because the stream 
of air, in the swollen condition of the mucous membrane, 
or in the existence of particularly firm adhesion of the 
walls, can only overcome the hindrances for a free circu- 
lation, with the aid of the palatine muscles that open the 
tube. 

If during the air bath, for thus we designate the blow- 
ing of air through the catheter into the middle ear, we 
hear a rattling sound, we must determine whether it be far 
from or near the external ear, that is, if in the Eustachian 
tube or middle ear. We must also determine whether it 



AUSCULTATION OF THE EAR. 217 

results from a fluid gently moving to and fro, or from a 
more viscid one, and whether the rattling sound occurs 
only at the beginning of the air bath, or at every repe- 
tition. 

Certain loud, rattling sounds are even better recognized 
without the otoscope or diagnostic tube than with it. 
They arise from the entrance of the tube, at its pharyn- 
geal orifice. Frequently a loud, piping, trumpet like 
sound is mingled with them, if the cartilaginous portion 
of the tube projecting into the pharynx is placed in lively 
motion, as is often the case even when the catheter is in 
the proper situation. 

Mucous glands are very numerous at the pharyngeal 
entrance of the tube, so that we may distinguish their 
openings with the naked eye, and on the dead body we 
find a greater or less amount of glairy mucus deposited 
in them. 

We often hear a very near whistling, or loud hissing 
sound, if the membrana tympani has a very small perfora- 
tion, and we then find a drop or so of pus or mucus 
in the meatus, which has been driven through this hole 
from the cavity of the tympanum. 

If, at the same time, the otoscope or diagnostic tube is 
placed air tight in the auditory canal, an increased press- 
ure is felt upon the membrana tympani of the listener. 
The same sensation may be experienced when a large por- 
tion of the membrana tympani has become very much 
thinned. This "perforation murmur" is not generally 
present when the perforation is very large, or when there 
is no purulent or mucous secretion. If we hear only a 
far removed and indistinct sound, with the otoscope, we 
may refer it to various causes. The catheter may not be in 
the right position. If this be the case, the patient will 
have a feeling as if the air passed in his throat and nose, 
and a reintroduction will produce quite another sensation. 
28 



21 8 AUSCULTATION OF THE EAR. 

The catheter may, however, be placed properly, but the 
current of air may meet with some impediment. The 
end may be covered by a fold of mucous membrane at 
the mouth of the tube, and the free passage of air be pre- 
vented. The tube may be also obstructed by swelling, or 
by a firm adhesion of its mucous surfaces, or by dried 
secretion, not to speak of the very rare cases of cicatri- 
zation of the mouth of the tube. 

Auscultation may also produce a negative result, al- 
though the catheter is in the proper position, and the tube 
permeable, if the curvature of the beak is not in proper 
proportion to the lateral portion of the pharynx, and it 
does not lie between the lips of the tube. The same 
negative result may occur when the cavity of the tym- 
panum is no longer an air reservoir, whether filled by 
thickened secretion, or its walls lie in contact from swell- 
ing of its lining membrane, or adhesion of the opposite 
surfaces. 

All these conditions we shall study more closely at a 
subsequent period. An examination with the ear mirror 
(otoscope) will generally give us an idea as to the nature 
of the different conditions which may produce these nega- 
tive auscultatory results. 

Frequently, however, even with the greatest amount of 
skill and practice on your part, exerted on the most intel- 
ligent and tractable patients, the first examination with the 
Eustachian catheter will leave much to be decided at a 
second sitting, as to the condition of the cavity of the 
tympanum and the tube. Of course here, as in all other 
modes of examination, the less skillful and practiced is the 
examiner, the less intelligent and tractable the patient, the 
less will be the diagnostic results that the catheter will 
furnish. As a last resort, rhinoscopy, or the examination 
of the upper part of the pharynx, must be undertaken to 
determine whether the improper position of the catheter 



AUSCULTATION OF THE EAR. 2IO. 

or an abnormal condition in the ear, for instance, an adhe- 
sion of the walls of the tube, is the reason that the air 
does not enter. 

Catherization of the tube furnishes diagnostic conclu- 
sions to the eye as well as the ear. If we examine the 
membrana tympani during the so-called air bath, we may 
perceive that this membrane is variously affected in differ- 
ent cases, even when the stream of air is of the same de- 
gree of strength. Sometimes its whole surface, with the 
handle of the malleus, is moved outward very much, 
again it is feebly and slowly moved in some parts, while 
others remain fixed, or even appear more tense. We may 
only indicate these symptoms at this point, since we shall 
return to them in speaking of catarrh of the cavity of the 
tympanum, and consider them more at length. 

By repeatedly testing the hearing distance, and examin- 
ing the appearance of the drum during the air bath, we 
may draw a number of deductions, not only as to what 
extent the tube is permeable, and as to the secretion, but 
we may also determine how far the impairment of hearing 
or the tinnitus aurium may depend upon a closure of the 
tube, or upon other conditions in the ear that act in a me- 
chanical way. Some of these are collections of mucus, 
rigidity of the membrana tympani, etc. Such conclu- 
sions will have quite a deciding influence upon the diag- 
nosis, prognosis, and future treatment. 

As has been already mentioned, the patient generally 
feels the stream of air "in the ear," or "going out of the 
ear." This sensation of the patient, and the visible 
movement of the membrana tympani during the air bath, 
or douche, are not always in exact proportion to each 
other. It may be that the patient does not feel the cur- 
rent of air in the ear at all, and yet it forces the drum out- 
> ward. I remember one case, that of a reliable patient, 
who, after a treatment of several months, declared that he 



220 AUSCULTATION OF THE EAR. 

never felt the air pass into one of his ears, while he always 
had the ordinary sensation in the other, and yet the move- 
ment of the drum was greater on the former side than the 
latter. In this case there was complete loss of sensitiveness 
or an anaesthetic condition of the nerves of the cavity of 
the tympanum and the membrana tympani. Such cases, 
although of different degrees, are not very rare. 

• 

The catheter is, however, of much more value in the 
treatment, than in the diagnosis of aural disease. We 
may inquire, then, what good does the use of the catheter 
accomplish, and how may we employ it? In order to 
meet any preconceived opinions on this subject, we may 
answer these inquiries by a simple reference to facts. 

If we examine the membrana tympani while a powerful 
stream of air is blown in through a catheter properly in- 
troduced, we see, in all cases where very great resistances 
are not met with, that the membrana tympani is moved 
more or less outward into the auditory canal. At the 
same time we not only hear the current of air strike the 
drum, but we may also convince ourselves, objectively, by 
the sense of sight, that the air not only actually enters the 
cavity of the tympani, but that it also exercises a certain 
mechanical effect upon this part. 

It is evident that if there is such an effect on the .'mem- 
brana tympani, there must have been a considerable effect 
while the stream was passing to it. The walls of the 
Eustachian tube are not only separated from each other, 
but all hindrances to the passage of air in it, and the 
cavity of the tympanum, such as mucus and pus, will be 
put in motion by the current, and driven either into the 
mastoid cells, or into the throat. This air bath, for we 
may so designate it, acts as a cleanser of the Eustachian 
tube, and of the cavity of the tympanum, and restores 
the connection between the throat and the latter, if it 



THERAPEUTIC VALUE OF THE CATHETER. 221 

has been* interrupted from any cause. Moreover, as we 
may see, the membrana tympani is moved outward, and 
thus any abnormal adhesions of this membrane must of 
necessity be stretched, and under very favorable circum- 
stances be even loosened. This last named purely me- 
chanical influence on adhesions in the cavity of the tym- 
panum, we may verify 1 by observations on the cadaver. A 
consideration of the effect of a douche, as observed upon 
these adhesions, will convince you that we may quite often 
loosen a synechia in the cavity of the tympanum. Such 
an effect occurs in those cases where a single introduction 
of the catheter has been of great use in restoring hearing; 
cases which have hitherto been called "accumulations of 
mucus in the middle ear." This effect of the air bath, 
which is quite common, because the adhesive process in 
the cavity of the tympanum is among the most frequent 
of the pathological conditions in the ear, has been hith- 
erto entirely overlooked by aural surgeons. We may only 
explain the oversight by considering the neglect of an ex- 
amination of the membrana tympani, and the insufficiency 
of the previous methods of illuminating the ear. We 
should never omit, after the employment of the air bath, 
or douche, to examine the ear very carefully, because we 
are thus enabled to see what effect we have produced, and 
on what anatomical conditions the improvement in hearing 
depends. 

Up to this time all the observations which have been 
made as to the effect of condensing or rarefying the air in 
the cavity of the tympanum, have been referred to the 
effect produced upon the membrana tympani alone, as if it 
were not a mechanical law that an effect should be produced 
in all directions where the stream of air passes. Politzer 
was the first to show the one-sidedness of this view, one- 
sidedness in the strongest sense of the word, and he 

i Vide Virchow's Archives, vol. 17, sec. 5. 



222 THE AIR DOUCHE TO THE EAR. 

showed, experimentally, that each rarefication dr conden- 
sation of the air in the cavity of the tympanum must 
act not only on the membrana tympani, but also on 
both the fenestras, because their elastic coverings, the 
membrane of the fenestra ovalis, and fenestra rotunda, 
with the membrane surrounding them, must be thereby 
distended. 

Repeated introduction of streams of air will remove a 
recent or commencing rigidity. It may possibly break up 
an anchylosis of the stapes, and restore the lost elastic- 
ity of the membrane of the fenestra rotunda. These ad- 
hesive processes occur very often in these parts, and their 
occurrence has such a great effect in diminishing the hear- 
ing that the use of the catheter becomes very important. 

It is evident that even when the pressure of the air is 
the same, the effect upon the fenestral membranes may be 
different, according as the movements of the membrana 
tympani are free or restricted, as it is abnormally relaxed 
and very movable, or greatly thickened and fixed. If we 
intentionally lessen the excursive power of the drum 
during the air bath, by pressing a finger into the external 
meatus, or by filling the auditory canal with water, the 
head being inclined to one side, the mechanical effect of the 
douche will be more strikingly felt upon the elastic por- 
tions of the labyrinth wall of the cavity of the tympan- 
um. In certain cases this effect is much to be desired. 

Among the interesting appearances after or during the air bath, are 
mucous vesicles in the cavity of the tympanum, whose outlines may 
be seen through the membrana tympani. Politzer has recently de- 
scribed a case of collection of serous fluid in the cavity of the tym- 
panum. The hight to which this arose was indicated in the mem- 
brana tympani by a hair-like black line, which moved downward 
when the patient exchanged his upright position for a horizontal one. 
I saw a similar change of position of the bubbles of mucus, in two 
cases. During the air bath quite a large vesicle, reaching into the 



THE AIR DOUCHE TO THE EAR. 223 

auditory canal was formed from the posterior and upper portion of the 
drum, which in one case had somewhat the appearance of a rasp- 
berry, and which in both cases extended over the end of the handle 
of the malleus, as it were, covering it. In both cases there were 
decided evidences of abnormal adhesion of this portion of the mem- 
brana tympani. After each air bath the same shaped vesicle formed, 
without any pain, but with marked improvement to the hearing. It 
disappeared in about half an hour. I can only explain this rare 
occurrence by supposing that a small loss of substance has occurred in 
the membrana tympani j that a small hole exists in the mucous and 
fibrous layer, allowing the passage of the air under the superficial 
integumentary layer. 

(Dr. Weir, surgeon to the Eye and Ear infirmary of this city, has 
furnished me with the notes of a case where, after an inflammation 
of the cavity of the tympanum had lasted one week, " the membrana 
tympani was thickened and reddened, but partly transparent, and 
through it is seen, on the Valsalvian experiment, a bubble of air, 
rising and falling. Air entered, as heard by the diagnostic tube, 
slowly, with little crackling sound. Frequent inflation of the drum 
caused the ear to feel better, and the hearing was improved." The 
observation was again verified, and the patient made a good recovery. 
I once saw a patient of Dr. C. E. Hackley's, also a surgeon to 
the infirmary, where the integumentary and fibrous layers of the 
drum were absent at one point. The passage of the air into the 
cavity of the tympanum caused a flapping sound. St. J. R.) 

I would take this opportunity to speak of an objection 
which older members of the profession make to the use of 
the catheter. Many fear to use it because they believe it 
is very easy to blow mucus from the throat into the cavity 
of the tympanum, and thereby cause injury. I do not 
doubt but that this sometimes occurs at first ; but if we 
do not stop at a single blowing, the mucus will certainly 
come out again into the throat, or into the cells of the 
mastoid process, which lie on the same plane with the en- 
trance of the Eustachian tube into the cavity of the tym- 
panum. Consequently the course and power of the stream 
of air must be directed against these cells. I have never 



224 OBJECTIONS TO EUSTACHIAN CATHETER. 

seen any injury produced from blowing air into the cavity 
of the tympanum, although I have introduced the catheter 
a countless number of times. We should call to the recol- 
lection of these theoretical gentlemen the fact, that the 
catheter is much smaller than the pharyngeal entrance of 
the tube, and that consequently it is not tightly held in 
the opening, and that there is always a large returning 
stream of air, in which all the moving bodies will fall 
which lie beyond the bony portion of the canal. The 
tenacious mucus which is in the throat will certainly, 
therefore, be oftener blown into the throat than the ear. 

There are other objections, such as that the catheter 
irritates the mucous membrane, a view which Toynbee 
also takes, but these are still less reasonable, and they 
have no force until some one wishes to use the cathe- 
ter who knows nothing of the modus operandi of its em- 
ployment. Generally speaking, Raus remark may be 
applied to these cases of fear of the use of the Eustachian 
catheter, when he says: " The principal objection of most 
opponents rests in their want of dexterity in the use of 
the instrument." 

The effects of catheterization, which we have hitherto 
observed, are generally transient in their nature, or at least 
they gradually diminish in importance. We generally de- 
sire to secure a lasting influence on the affected membrane 
of the middle ear, for, after the removal of the secretion, 
or the separation of the opposing surfaces, the mucous 
membrane will still remain affected. Local treatment is 
only possible by means of the Eustachian catheter; it 
serves as a vehicle for introducing various remedies, which 
act directly on the tube and on the cavity of the tympanum. 
Such medicaments are employed either in the form of flu- 
ids, or of vapors or gases, of whose value we shall subse- 






METHOD OF INJECTING FLUIDS AND VAPORS. 225 

quently speak in detail, in the lecture on chronic catarrh 
of the ear. 

We have still to mention that the catheter may be 
used as a vehicle for the introduction of solid bodies 
into the tube, and possibly into the cavity of the tym- 
panum. Such bodies are probes of metal, whalebone,' or 
catgut, or copper wires, for transmitting electricity. We 
shall learn the special value of the introduction of these 
instruments at a later period. 

We generally use a gutta percha bag or syringe for the 
purpose of forcing medicated fluids or vapor into the ear, 
the nozzle of this being inserted into the funnel-shaped 
orifice of the catheter. The custom of blowing the air into 
the catheter from the mouth of the surgeon, as may be 
done when we wish to give a simple air bath, is a method 
not to be recommended for introducing these agents, even 
if there be no bad odor in the breath. In cases where 
the resistance from the walls of the tube is unusually 
great, a fact easily recognized by the hand which com- 
presses the air bag, or when from any other reason a more 
powerful current of air seems desirable, we may advan- 
tageously use a compression pump, not only for the air 
bath, but also for the subsequent treatment with vapors 
and gases, or with injections. (I have entirely abandoned 
the use of the compression pump, after a brief and unsat- 
isfactory experience with it, and use only the air bag, which 
I find to answer all purposes. St. J. R.) The compression 
pump which I use consists essentially of a quite thick glass 
bell, forty centimetres high, and twelve broad, which is fast- 
ened on a wooden support by means of a strong measuring 
tub. There is connected with this a pump* twenty centi- 
metres long and four centimetres in diameter, which, with 
its wooden support, rests on the table. In the tube which 
connects the ball with the pump there is a faucet which has 
an opening for the entrance of external air, and is besides 
a 9 



226 



COMPRESSION PUMP. 



perforated by a horizontal opening, through which the 
air pressed by the pump passes. The faucet for the regu- 



Fig. 20. 




o^.vi?\'e.\.T>- ■aWQ'i=>. 



Air Receiver and Pump. 

lation of the exit of air, is on the top of the bell, and 
there is a gutta percha tube added to it, which leads the 
air into the catheter or heating apparatus. The measuring 
tube at the bottom of the glass bell is fastened on by a 
screw, which must be air tight, and admit of removal 
for cleaning. I have tried very many apparatus, and I 
believe the one which I have just described is the best. 
Air bags, single and double, are used by many physicians 
instead of the* pump. Some use hand bags, and others 
those that are so large as to be placed under the table and 
moved with the foot. 

Very recently, Lucae, of Berlin, proposes to use two air 
bags, one of which is of thin rubber, and, having a venti- 



GLASS FLASK. 227 

lator, acts as an air reservoir. Usually, however, a sim- 
ple unvulcanized air bag, vigorously compressed by the 
hand, is sufficient. I now make infrequent use of the 

Fig. 21. 




Glass Flask for generating vapor. 

pump. I use a simple glass flask for the generation 
of the vapor, which is placed on a sand bath, and heated 
by means of a spirit lamp. The cork of the bottle 
is bored in four places, one for the funnel-shaped glass 
tube, to which a stopper is adjusted, one for a thermome- 
ter, and the remaining two for the entrance and exit of the 
heated air, conecting respectively with the gutta percha 
tube from the pump, and with the catheter. In order to 
steady the flask an iron support passes around it. 



228 APPARATUS FOR INJECTION OF VAPORS. 

(Dr. Moos, of Heidelberg, recommends a method of in- 
troducing the vapor of muriate of ammonia which the 
accompanying figure and description will make clear. 

Fig. 22. 




apparatus for generating muriate of ammonia. 

The apparatus consists of three glass flasks, two of 
which contain hydro-chloric acid and ammonia. They 
each have a cork with two holes in it; one for the tube 
leading in, and the other for the tube leading out of 
the flask. The third glass flask contains compressed air, 
in which hydro-chloric acid and vapor of ammonia are 
combined, and in which the vapor of ammonia is found 
in a state of generation^ and which necessitates a third cork 
having three holes in it, because from hence the vapor is 
driven out through the conducting pipe that leads into 
the catheter. The tubes of the first two flasks {a and b)> 
when they unite with the tube of the pump, may be very 
properly united in one by means of a fork-shaped tube 
made of horn. St. J. R.) 



APPARATUS FOR HOLDING CATHETER. 



229 



Generally the catheter may be held with the hand of the 
surgeon, after it has been introduced into the mouth of 
the tube; at the same time it is well to place the left finger 
on the cheek or nose of the patient. 

When the patient is intractable or awkward, or when 
the catheter is to remain a long time in its position, 
we should fasten it by some mechanical contrivance. A 
number of instruments have been proposed for this 
purpose. 

Kramer s frontal band was formerly most frequently used 
for this purpose. This consists of a small, roundish pad 
resting on the forehead, to which a screw forceps is at- 
tached by means of a ball and socket joint. 

Fig. 23. 




Spectacle Forceps. 

Rau advises the use of a spectacle forceps, that is, a 
spectacle frame with a forceps attached, which may be fast- 
ened in any position desired by means of a screw and slide. 
Very recently I have used a nose pincers, first suggested by 
Bonnafont, and modified by Luc*. 



230 



NOSE FORCEPS. 



If the catheter be properly introduced and fastened, the 
patient will be in no manner prevented from swallow- 
ing or speaking. He is generally able to sneeze without 
displacing the catheter. In fact it may remain for hours 
if necessary. 

Fig. 24. 




Nose Forceps. 



LECTURE XV. 

Valsalva s and Politzers method of inflating the middle ear; 

other inferior methods. 

Gentlemen: We may to-day pass in review a number 
of methods of inflating the middle ear that may in some 
cases, at least, accomplish results almost identical with 
those which are obtained by catheterization of the Eustach- 
ian tube, or which may act as substitutes for this procedure. 

The Valsalvian Experiment. — Valsalva's experiment 
consists in pressing the air into the ear, after a powerful 
inspiration, the mouth and nose being closed. This 
method is termed, by the English, blowing up or inflat- 
ing the membrana tympani. It is of a certain value in the 
treatment of the patient by himself, as we shall have occa- 
sion to learn. It causes a sort of condensation of the air 
in the cavity of the tympanum, and the membrana tym- 
pani is at the same time generally pushed somewhat out- 
ward. This pushing out of the membrane may be most 
distinctly observed on the posterior and upper border, at 
the extensive reflection of light there existing. 

In examining patients, however, for the purpose of di- 
agnosis, you will seldom have occasion to make use of 
this method. In very many persons, especially those very 
hard of hearing, it will certainly take more time and 
trouble to teach them this method than is necessary for 
the introduction of the catheter and the employment of 
the air douche. In employing the Valsalvian method we 
are limited to the statement and reliability of the patient 
as to whether the air enters the ear or not, unless we can 



232 THE VALSALVIAN EXPERIMENT. 

at the same time examine the membrana tympani, which 
we are not always able to do at the first attempt. Further- 
more, even if the experiment succeeds, we learn nothing 
except that the tube is permeable. We obtain no further 
idea from it" of the state of the tube, or of the middle ear. 
In some cases, however, a loud whistling or hissing sound 
is noticed during the inflation, when the catheter and air 
douche do not show any symptoms of increased secretion 
of mucus. 

Not unfrequently patients believe that they are affected 
with a perforation of the membrana tympani, because they 
can produce such a whistling sound in the ear, which has 
a certain similarity to the sound of air passing through a 
perforation. But it is also true that some patients who 
have known how to use this method for a long time, are 
not able at times to force the air into the ear, while a vig- 
orous blowing in of the air through the catheter shows 
that the tube is permeable. 

The diagnostic value of the Valsalvian method, as 
compared with that of the catheter, must be regarded as 
very little. It may be rather considered as an assistance to 
be used in a case of necessity, but as a means which is not 
to be relied upon. I may also call your attention to the 
fact that not a few patients practice this method very im- 
properly, although they imagine that they understand it 
very well, because they have been accustomed to employ it 
very frequently for physicians who do not willingly use the 
catheter. Instead of simply forcing the air in, a half swal- 
lowing, half sucking movement is made, by such persons, 
so that the air is not only not rendered denser, but it is actu- 
ally rarified. I have observed a few cases where, in the per- 
formance of this experiment, the air passed out through the 
lachrymal punctum, and the patients only felt the air in the 
ear, when the finger was pressed upon the inner canthus of 
the eye. 



THE VALSALVIAN EXPERIMENT. 233 

Toynbee believed that we were able to fully dispense with 
the catheterization of the Eustachian tube, as a diagnostic 
aid. He endeavored to determine the permeability of the 
tube by means of a method which may be called the nega- 
tive Valsalvian experiment. He caused the patient to swal- 
low while he auscultated the ear with the otoscope, or diag- 
nostic tube. If the Eustachian tube is permeable, a sensa- 
tion of fullness in the ear is experienced, a peculiar cracking 
sound is said to be heard, which is not the case if it be 
closed. Toynbee himself, however, confesses that the sound 
is sometimes wanting, when we know by other means that 
the tube is permeable, and that it may occur when other 
signs indicate that the tube is closed. In short we have 
only to read the testimony of the author, 1 to convince 
ourselves how unreliable for diagnosis, and how little to 
be trusted, this method is. Toynbee, who was the founder 
of the modern system of the pathology of the ear, was in 
error in not employing catheterization of the ear in the 
examination, and unfortunately also in the treatment of 
aural diseases. 

Toynbee' s method, however, has its uses. If we look 
at the membrana tympani while the patient swallows with 
his mouth and nose closed, we find a variable condition of 
the membrane. It is shown by manometric experiments 
that a rarefaction of the air in the cavity of the tympanum 
then takes place. Sometimes the anterior and inferior 
segment of the drum moves outward, but it is more com- 
monly drawn inward, while its upper portion is pushed 
out, and again it does not move at all, although the tube 
is permeable both when the catheter is employed, and 
when the patient himself presses in the air. Such move- 
ments are sometimes perceived with this experiment, when 
the Valsalvian experiment produces only a negative result. 

1 Diseases of the Ear, p. 196. 

3° 



234 politzer's Method. 

In partial atrophy of the membrana tympani, especially in cases 
where large perforations have been healed, such movements are seen 
on the thinned portions of the membrane, as often as the motion of 
swallowing is made, even when the nose is not closed. 



Politzer's Method. — We may now turn to the consi- 
deration of a very important method of inflating the cavity 
of the tympanum, which is called after the name of its 
inventor, Politzers method. 

This method was suggested by Dr. Adam Politzer y of 
Vienna, in 1863. It consists essentially in the following: 
The air is forced into the nasal cavity by blowing from 
without at the same instant that the patient swallows. The 
air in the naso-pharyngeal can only be rendered denser, of 
course, when this space is changed into a closed cavity. 
This is effected by the surgeon, anteriorly, who closes the 
nasal passages by pressing them together with the fingers. 
The cavity is closed posteriorly by the act of swallowing, 
during which the upper pharyngeal space is shut off from 
the lower by the soft palate, which lies back against the 
pharynx. The act of swallowing also causes the pharyn- 
geal orifice of the Eustachian tube to open. Thus a way 
is opened by which the entering stream of compressed air 
meets with but slight resistance to its entrance through the 
tube into the cavity of the tympanum. 

The manipulations necessary in carrying out this method 
are extremely simple. A straight or slightly curved tube 
is first introduced into the entrance of the nasal meatus, 
for about half an inch. Then the nostrils are both closed 
by slight pressure with the fingers. We have then only 
to cause the patient to swallow at the same instant that air 
is blown through the tube. It is well to cause the patient 
to take a little water in the mouth just before, in order 
that he may be able to swallow exactly at the proper time. 
The air may be forced in by the mouth, or by the india 



POLITZER S METHOD. 



235 



rubber bag. A slightly curved tip or nozzle may be con- 
nected to the india rubber bag by means of a piece of 
india rubber tubing. 

Fig. 25. 




Politzer's method of inflating the cavity of the tympanum. 

In all cases where the resistance from the walls of the 
tube is not too great, the air in the middle ear is con- 
densed by the above described procedure. The patient 
becomes aware of this by a certain pressure in the ear, and 
on examining the membrana tympani at the same time, it 
is seen to be bulged out externally, especially posteriorly 
and above. The diagnostic tube, or otoscope, rarely fur- 
nishes any conclusion as to the entrance of the air, because 
the sound produced by the muscles and the water drowns 
the slight sound occurring in the middle ear. When a 
perforation of the membrana tympani exists, a very loud 
whistling or hissing sound generally occurs, while at the 



236 politzer's method. 

same time the secretion from the middle ear is driven into 
the auditory canal, and sometimes even to its outer ex- 
tremity. The action of Politzer's method is similar to 
that from the air douche with the catheter, and to that of 
the Valsalvian experiment. 

As compared with the use of the Eustachian catheter 
we notice especially the great and peculiar simplicity of 
the method. Any person may employ it with any other 
person, always excepting the very rare cases where the 
naso-pharyngeal space cannot be closed in consequence of 
fissure of the palate, etc. 

There are none of the hindrances in the performance 
of this operation, either to the surgeon or the patient, 
that may arise in the use of the Eustachian catheter. As 
has been already said, cases sometimes occur where the 
catheter cannot be used without great pain or hemorrhage, 
on account of some abnormal condition of the nasal 
meatus. With the constantly increasing practice of the 
surgeon such cases constantly become more rare, and we 
may possibly introduce the instrument from the other 
side. But this roundabout way does not always allow the 
desired result to be accomplished, and it may be that both 
nasal passages are impermeable. For all such cases, we 
have found a substitute for the catheter in this new method, 
and a means of relieving ourselves from the unpleasant 
position of leaving a state of things unimproved which 
might perhaps be corrected, were it not for the accidental 
local conditions. 

In the beginning of your practice you will not unfre- 
quently meet with patients who make great objections to 
the use of the Eustachian catheter. In the case of healthy 
adults it will be proper to meet such persons with a quiet 
persistence in your determination to use the instrument 
when necessary. If you do not you will never acquire the 



POLITZER S METHOD. 237 

confidence of your patients, or obtain any experience in 
catheterization. 

The matter is quite different, however, when you are 
dealing with children, or with persons who are very 
weak, or prostrated by constitutional disease. In these 
cases we were formerly obliged to forego any considerable 
local treatment, but we now have the means, in Politzer's 
method, at least in recent cases, of obtaining the same or 
similar curative results as with the catheter. Not unfre- 
quently, at a later period in the treatment of such patients, 
when we have acquired their confidence, we may, if neces- 
sary, pass on to the use of the catheter. 

Politzer's method of inflating the middle ear is much 
more important for the great mass of practitioners than 
for you, gentlemen. They, are generally not acquainted 
with the mode of using the catheter, and are apt to cause 
the patient a great deal of pain in introducing it, without 
doing him any good. It is of inestimable value to have 
a means for the use of such practitioners, which they can 
safely and certainly employ in certain diseases of the ear, 
and with which they may exert a favorable influence upon 
the course of the affection. We shall have occasion to 
speak of the great frequency of aural catarrh, especially as 
it occurs in a class of mild and severe constitutional affec- 
tions, at a subsequent meeting. 

This new method, finally, is extremely useful in those 
cases where we desire that patients should treat themselves. 
They easily learn how to employ it. Great care should 
be taken, however, in instructing patients. It is not 
sufficient to place an india rubber bag in the hands of the 
patient, but he should be taught not to rarefy the air in 
the middle ear after it is made denser, as is done by many, 
and even by physicians, by not closing the air bag when 
withdrawing it from the nose. Air bags and india rubber 
tubing are also sometimes used, that blow dust and other 



238 politzer's method. 

substances into the ear. (It is well to caution patients 
who are advised to use Politzer' s method, against its too 
frequent employment. I heard of one patient who injured 
her ear by using the air bag every hour for several days. 
St. J. R.) 

It is only in rare cases that we can instruct the laity how 
to use the catheter. Patients who require that the air 
should be frequently and regularly forced into the ear, have 
been until recently limited to the Valsalvian experiment. 
This, however, is in very many cases very inferior to Po- 
litzer's method. 

We may now inquire, how does the new method differ 
from that of Valsalva? Chiefly in the fact that it acts more 
powerfully, and more certainly accomplishes its object. In 
the Valsalvian experiment the pressure caused by the forci- 
ble contraction of the expiratory muscles, is distributed 
over the large surface of the thorax, and of the respiratory 
tract, with the upper and lower pharyngeal space, before it 
acts upon the walls of the tube. 

In Politzer* s method, on the contrary, the resistance of 
the adherent walls of the tube is considerably diminished 
by the action of swallowing. Besides, the surface on 
which the force of the condensed air distributes itself, is 
only the naso-pharyngeal space. It is therefore much 
smaller than when the Valsalvian method is employed, 
while the force exerted is much greater. Added to this, 
Politzer has already shown by experiment that the column 
of mercury in the manometer can be raised much higher 
by the pressure of the hand upon an air bag, than by the 
expiratory muscles. We need not be surprised, therefore, 
that we are unable to overcome resistances in the tube by 
the Valsalvian procedure, which the method of Politzer 
very easily accomplishes. 

Besides the fact that the Valsalvian method is less 
powerful, there are other objections to its use. Our 



POLITZER S METHOD. 239 

ear patients are very frequently children, who can scarcely, 
unless they have passed a certain age, at least, learn 
to force the air into the ear. It is in infantile prac- 
tice that Politzer's method furnishes its most brilliant re- 
sults, since the friends of the patients can readily learn to 
employ it. We should not omit to mention, that a 
very considerable hyperemia in the head and ear often 
occurs from practicing the Valsalvian experiment. This 
appears especially if, in spite of an intense exertion of 
strength, the resistance of the wall of the tube cannot 
be overcome. We frequently see the face of the patient 
becoming red during the exertion of the force, and the 
veins on the surface of the head and neck become more 
turgid and swollen in consequence of the hindrance to the 
return of the blood. The vessels of the membrana tym- 
pani also become more injected, as may be observed with 
the mirror. The patients also complain of increased 
noise in the ears, and of a painful sense of fullness in the 
head. Such an artificial congestion excited in old persons 
with atheromatous cerebral arteries, may not be an indiffer- 
ent matter. In the case of an extremely myopic patient 
from the country, with a large posterior staphyloma of each 
eye ball, a severe frontal pain, beginning from the eye, 
with a very annoying sensation of sparks before the organ, 
always accompanied the performance of the Valsalvian 
experiment, so that I was compelled to cause him to desist 
from forcing air into the ear, lest a choroidal hemorrhage 
or detachment of the retina should occur. This method 
was unfortunately, then, the only means that this patient, 
who could but seldom come into the city, had of tempo- 
rarily diminishing a very great impairment of hearing, and 
of preventing its increase. 

Politzer's method is to be infinitely preferred to the 
Valsalvian experiment. The latter has but one advantage 
over the former, that is, that no other assistance than the 
hand is needed for its performance. The relations of the 



24O POLITZER S METHOD. 

new method to the catheter, however, are somewhat differ- 
ent. It can only be substituted for the Eustachian cathe- 
ter under certain circumstances, although when these occur 
it is an extremely valuable substitute. If there be no 
hindrance, either in the condition of the parts, or the age 
or general condition of the patient, or, furthermore, in 
the skill of the physician, to prevent the use of the cathe- 
ter, it will have for very many cases very great advantage. 
In others very much may be accomplished by Politzer's 
method alone. 

There is a very considerable difference in the character 
and effect of the current of air, whether introduced by 
one method or the other. In forcing the air in through 
the catheter we have a current of air passing against the 
resistances in the tube, which gradually makes a way for 
itself, and which after a time acts upon the walls of the 
cavity of the tympanum, and whose force may be gradu- 
ally increased. The degree of -the effect may be varied in 
different ways, apart from the amount of pressure that 
may be exerted, by using a larger or smaller catheter as to 
caliber, or one with a longer or shorter beak, or by caus- 
ing the patient to swallow as the air is forced in, and also 
by closing the nose at the same time. 

In Politzer's method, on the contrary, the compression 
of the air is very sudden and precipitate. We are not 
able to regulate very efficiently the amount of force used, 
or to decide beforehand how great it will be. At the same 
time it acts not only on the middle ear, but on the exten- 
sive surface of the naso-pharyngeal space, with the adja- 
cent cavities, in the frontal, superior maxillary and sphe- 
roid bones. If, therefore, we wish to get a current of air 
of long duration, as well as a high degree of the compres- 
sion of the air, such as may be obtained by the use of the 
compression pump, we should never employ Politzer's 
method, because we cannot always succeed in overcoming 
great resistances by its use. 



POLITZER S METHOD. 24.I 

The sensation of pressure in the neck (Prellung) some- 
times experienced in the use of Politzer's method, is ex- 
tremely unpleasant. This chiefly proceeds from the soft 
palate, which undergoes a double pressure — above, from 
the compressed air, and below, from the water which is 
compressed by the muscles. 

This sensation is sometimes felt by children after the 
operation, in the stomach, and may cause a severe pain 
in this part, or in the diaphragm. 

I remember the case of a child of four and a half years of age, that 
came under my care, who much preferred the catheter to Politzer's 
method, on account of the pain in the stomach which the latter 
caused. This child always cried bitterly when it was desired to use 
Politzer's method, but submitted quietly to the use of the catheter. 

(I have never attempted to use the catheter in very young child- 
ren, because they make so much objection, until they learn just what it 
is, even to the introduction of the nose piece of Politzer's instrument 
into the nostril. I have despaired of succeeding in any attempt to 
introduce the catheter, which always produces an unpleasant sensa- 
tion. I have never seen any of the cases of which the author is 
now speaking, although I am in the daily habit of employing Po- 
litzer's method on children. St. J. R.) 

A more important disadvantage of the new method is 
that we cannot localize the effect. If the resistance in 
both tubes or tympanic cavities be exactly the same, the 
air rushes into both, but when the conditions are unequal 
the air always takes the course where the resistances are the 
slightest. This effect is most disturbing where one'mem- 
brana tympani is perforated, or partially atrophied, because 
the compressed air enters one ear alone, or chiefly so, no 
matter in which nostril it is introduced. In all such cases 
we must necessarily use the catheter. Sometimes the 
influence of the perforation may be overcome by hermeti- 
cally closing the external meatus by means of the finger, 
or the like. 

3 1 



242 POLITZER S METHOD. 

In some cases the fact must be taken into consideration 
that in the use of the Eustachian catheter, it is only re- 
quired that the patient remain passive, while in Politzer's 
method the assistance of the patient is necessary — he must 
swallow, and at a certain moment. 

Lucae and Hinton state that they overcome this objection by com- 
pressing the air in the naso-pharyngeal space by blowing through an 
elastic tube for some seconds at a time, allowing the patient to swal- 
low the water at the instant he may choose. 

Patients afflicted with diseases of the ear are not spe- 
cially noted for quickness of perception, but on the con- 
trary every physician who has much to do with this class 
of persons, knows how many awkward people are found 
among them, apart from the difficulty of instructing any 
person who hears badly, or is deaf, in the necessary manipu- 
lations for a successful employment of Politzer's method. 
It should, however, be remarked here, that it is only in 
adults that the simultaneous act of swallowing is an essen- 
tial thing. In small children, very often, if not always, 
the compressed air passes from the nasal cavities into the 
ear without this assistance. The absolutely greater width, 
or more properly the greater capability of distension, of 
the infantile Eustachian tube, may be the cause of this 
exceptional condition, which increases the value of Po- 
litzer's method of inflating the middle ear, for practice 
among children. 

Finally, the new method can by no means limit the 
value of the Eustachian catheter as a vehicle for the intro- 
duction of solid bodies, e. g., bougies, or for injecting 
fluids or vapors into the ear. 

By first filling the air bag with vapor, or fluid, we are 
of course able, on closing the nose and causing the patient 
to swallow, to inject some of it into the ear. There are, 
however, other disadvantages attached to this method than 



POLITZER S METHOD. 243 

the one that in the procedure a great portion of the vapor 
is precipitated on the sides of the syringe. The diffusion 
of this vapor on the whole naso-pharyngeal space is by no 
means an indifferent matter. Besides, the force with which 
we thus inject fluid into the ear must be quite great. The 
effect of this unelastic body may easily be too great, and 
more than can be previously estimated. The observations 
of Saemann, who first recommended the injection of water 
by means of Politzer's method, under the name of "water 
douche of the Eustachian tube," sustain the above opinion. 
Together with a number of cases where this method of 
treatment proved very favorable, without any unpleasant 
reaction worth mentioning, he also observed cases where 
vertigo and a sensation of faintness, severe pain in the ear 
and in the mastoid region occurred, together with a worse 
condition of the hearing, lasting for several days. 

Very recently Joseph Gruber 1 has recommended a 
method of inflating the middle ear that may be designated 
as a development of the Valsalvian experiment. It is es- 
pecially recommended for cases where the naso-pharyngeal 
mucous membrane is affected, as well as the ear. While 
the patient holds the head in such a manner that the nasal 
meatus has a horizontal direction, a medicated fluid is in- 
jected into one nostril by means of a syringe holding 
about an ounce and a half. In the case of children it is 
only necessary to shut the other nostril, when, as a rule, 
a portion of the fluid that has been injected will pass 
through the tube into the cavity of the tympanum, and 
when the membrana tympani is perforated will even run 
out of the auditory canal, especially if the act of swallow- 
ing be performed at the same time. In adults, where the 
narrowness of the tube is not so favorable for this method, 
a blowing motion is made by the patient, with the mouth 
and nose closed, immediately after the injection, which 

1 Deutsche Klinik, 1865, Nos. 38, 39. 



244 



POLITZER S METHOD. 



forces a portion of the fluid through the tubes, into both 
cavities of the tympanum. 

The modification of the air bath before alluded to (page 
1 8 8) j in which we endeavor to make the membrana tym- 
pani as rigid as possible, by external pressure,- in order 
that the membranes of the fenestra? may feel the more 
powerfully the mechanical influence, also applies to the 
Valsalvian and Politzer's method. In practicing the 
former the two thumbs are pressed powerfully on the ears, 
while the nose is closed by the middle finger. In 'the lat- 
ter method the auditory canal is closed by the finger of a 
third person, or by means of an india-rubber stopper. 

We may here notice a little instrument adapted especially for 
physiological demonstration of the vibrations of the air in the middle 
ear, as well as to show the permeability of the Eustachian tube, 
the influence of the acts of swallowing and respiration upon the 
membrana tympani, etc. It was first suggested by Politzer. It 

consists of a horseshoe shaped glass tube I 1-2 mm. in caliber, which 

f 

Fig. 26. 




Politzer' s Manometer. 

is fastened in the auditory canal by means of a hard rubber nozzle 
smeared with grease. A drop of a solution of carmine, contained 



POLITZER S METHOD. 245 

in this aural manometer, indicates, by rising and falling, the variations 
in the pressure of the air in the auditory canal and cavity of the 
tympanum. 

According to Lucae it is very difficult to keep the 
manometer in position. He therefore uses a gutta 
percha tip, for introduction into the meatus, that has been 
previously warmed. This will not become looser even 
by repeated motions of the lower jaw. 

(It may be worthy of remark, in addition to what has been said in 
the foregoing pages, that Politzer's method is particularly applicable 
in those cases of sub-acute catarrh of middle ear, occurring in young 
persons, which are so frequent in the vicinity of New York. Be- 
fore the introduction of this method We had like means at our com- 
mand for the relief of the most annoying symptom — the deafness. 
In America, at least, the use of the Eustachian catheter will hardly 
be made available for young persons, as useful and indispensable as it 
is in the case of adults. I add a few cases taken at random from 
others, first published in one of our journals, 1 which illustrate the 
great boon conferred upon the public by this means of treatment. 

Case I. Willie S., aged 11, April 28, 1865. Has been grow- 
ing deaf for some months, is rather delicate. His appetite is ex- 
tremely capricious, drinks tea and coffee in great excess. He cannot 
hear ordinary conversation. The left membrana tympani is of a 
pinkish hue, the right secretes a slight amount of pus, is however 
intact. The tonsils are somewhat enlarged. Hears an ordinary 
ticking watch (which should be heard from three to five feet) five 
inches on the right side, one inch on the left. Politzer's method is 
practiced two or three times, when the hearing distance was doubled 
by the watch on the left side, and ordinary conversation was heard 
with some ease. He was seen every day or two until May 4th, 
when he returned home, hearing the watch more than two feet on 
the left side, and six inches on the right, and was not at all perceived 
to be deaf in conversation. The appropriate constitutional treatment 
was carried out, only nutritious diet was allowed, an astringent was 

1 American Journal of the Medical Sciences, Vol. LIII. p. 62. 



246 CASES TREATED BY POLITZER's METHOD. 

applied to the right drum, and Politzer's method was practiced every 
two days. This treatment was still carried on at his home by other 
hands, and the patient was heard from as being still further improved. 

Case II. F. S. B., aged 16, N. Y., September 1, 1865. Has 
been deaf at times for a number of years, and for the past summer 
persistently so. His general condition is fair; is well developed. 
The tonsils were so much hypertrophied as to impede respiration, but 
they were removed previous to his coming under my observation. 
The pharynx secretes excessively, as well as the nasal mucous mem- 
brane. There are numerous granulations scattered over the pharynx. 
The drums are pinkish, brilliant in appearance. The light spot is 
elongated. The watch is heard about six inches from each auricle. 
Politzer's method was practiced three or four times, when the hear- 
ing distance extended to sixteen inches on the right side, and ten on 
the left. A gargle containing *iodine and brandy was ordered to be 
used twice a day ; he was also to practice Politzer's method twice a 
week, in connection with an iodine inhaler. The patient continued 
to improve, and at the present writing, April 20, 1866, the treatment 
has been abandoned, the hearing power being nearly if not quite 
normal. The patient goes to school every day. He was seen by 
me for some weeks, once a week, while his father, who is a dis- 
tinguished physician of this city, carried out the treatment at home, 
which consisted in the use of the gargle, and inflating the middle ear 
by Politzer's method once in three or four days, with attention to the 
general health. 

Case III. Edgar S., aged 17, Connecticut, October 20, 1865. 
Since the patient was four or five years old he has had more or less 
trouble in hearing. A few years ago the ears discharged and pained 
at intervals. The general health is fair ; he is tall, well developed, 
except that he is pigeon breasted. Hearing distance with watch, 
right ear, one inch ; left, two inches. The right drum is sunken, 
and is quite white in color ; no light spot exists. The left drum is 
intensely reddened and sunken ; the centre seems to be united to the 
wall of the cavity of the tympanum. After the use of Politzer's 
method in combination with a bulb containing a sponge saturated 
with tincture of iodine, 1 a few times, the hearing distance on the left 

1 American Journal of Medical Sciences, January, 1866, p. 108. 



CASES TREATED BY POLITZER S METHOD. 247 

side was increased to eight inches, but it remained the same on the 
right. He also heard and pronounced after the speaker, words spoken 
eighteen feet off, while a few moments before he could only hear them 
six feet. A Politzer's apparatus was ordered to be used at home, 
under the direction of his father, twice a week for a month, a slight 
counter irritation to be kept up over the mastoid process, when he 
was to report himself. November 26 the patient again presented 
himself, having carried out the treatment as directed, and can now 
hear the watch on the right side three inches, on the left twenty 
inches and more. He hears conversation with ease. Patient was 
directed to desist from treatment. In 1868 his hearing remained good. 

Case IV. Michael W., aged 13, at Eye and Ear infirmary, No- 
vember 2, 1865, a delicate bright-looking boy. Whenever he has 
a cold (as his father says) "it falls to his ears and he gets deaf." 
Right membrana tympani pink and sunken ; left sunken, but of 
about normal color. Tonsils have been ulcerated : pharynx secreting 
excessively. Hearing distance, right ear four inches; left, three 
inches. He was seen twice a week until January 17, 1866, iodized 
air being used by Politzer's method at each visit ; cod-liver oil and 
ferri iodidi syrup were administered. He had occasional partial re- 
lapses, but was at the above date discharged cured. His hearing im- 
proved at the first use of the method very markedly. 



Fig. 27. 




Politzer's Air Bag with inhaler attachment. 

Case V. Girl aged 16, at ear and eye clinic in University Medi- 
cal College, March 28, 1866. Has not heard ordinary conversation 
for years, and has been very much embarrassed in swallowing and 
breathing on account of enlarged tonsils; general condition is fair; 
the voice is extremely nasal; only hears when addressed in a loud 
tone of voice ; the watch is heard two inches on the right side, one 



248 politzer's method. 

inch on the left ; membrana tympani present nothing striking in ap- 
pearance, except that they are quite brilliant ; the tonsils are excess- 
ively hypertrophied. The use of Politzer's method immediately 
improved the hearing somewhat, which improvement lasted, accord- 
ing to the patient's statement, about a day. When next seen the 
tonsils were exercised with the forceps and scissors, a long outgrowth 
being dragged down from behind the soft palate on the right side, 
which must have pressed upon the orifice of the Eustachian tube, 
and then the iodized air was driven into the tube. The hearing dis- 
tance became two feet on the right side, and about six inches on the 
left. An iodine gargle was ordered, with cod-liver oil, a half table- 
spoonful to be taken three times a day. The patient is now under 
treatment, and still, April 26, 1866, continues to improve, hearing 
very well, with no trouble in respiration. This patient fully recovered. 

The bulb figure on the preceding page contains a moist sponge, on 
which are placed a few drops of tincture of iodine. The combined 
apparatus is then used in the same manner as the ordinary air bag 
which constitutes Politzer's apparatus. St. J. R.) 



LECTURE XVI. 

METHOD OF EXAMINING THE ACUTENESS OF HEARING. 

The power of hearing the tick of a watch and understanding 
conversation^ as compared with each other; watching the 
mouth of the speaker ■, by a person with impaired hearing; 
how a measurer of the degree of acuteness of hearing should 
be constructed; better hearing in the midst of sounds; ex- 
cessive acuteness of hearing; conduction of sounds through 
the bones of the head; testing the reflection of sounds. 

Gentlemen: Since we are now to pass on to the con- 
sideration of the diseases that most frequently cause func- 
tional anomalies of the sense of hearing, this may be the 
most appropriate place in which to speak of the different 
varieties of disturbances of audition, and, at the same 
time, of the differeftt methods by which we ascertain the 
hearing power, or acuteness of hearing, of a patient. 

When we are dealing with that most common result of 
an affection of the ear, diminution of the hearing power, 
we must, in order to ascertain its degree, carefully regard 
two things which do not always stand in exact proportion 
to each other: first, how much the patient is prevented 
from hearing ordinary conversation; second, how far he 
can hear the sound of certain tone-giving, or vibrating 
instruments. 

We generally use a watch for the examination of the 
hearing power, ascertaining whether the patient can hear 
the ticking at any distance from the ear, or only when it 
32 



250 EXAMINING THE AMOUNT OF HEARING. 

is pressed close upon the auricle or bones. In the former 
case the wajch should be constantly held in .the same 
direction from the ear, for instance, parallel with the 
auricle; and instead of gradually removing the watch, 
you should cause it to gradually approach the organ. 
Thus you will best guard yourself against self-deception 
on the part of the patient. You will also learn at what 
distance the patient first begins to appreciate the tick of 
the watch, and the one where he can distinctly count the 
ticks. Some aural surgeons hold a measure of leather 
between the ear and the watch during this examination ; 
consequently a conduction of the sound occurs by means 
of the fixed body, and the result is quite different from 
that obtained when the air is the only conductor. 

We should previously make an examination of healthy 
persons with the same watch that we are using with 
the deaf, in order to correctly determine the normal dis- 
tance at which it can be heard. A watch with a clear 
tone should be chosen, if possible. Some watches have 
no tone at all, but only a smooth rubbing sound, and 
are therefore very poorly adapted for our purposes. For 
certain high grades of deafness we can only use repeating 
or striking watches. These have the* advantage that you 
can approach them to the ear, at one moment when they 
are striking, at another when they are not doing so; and 
thus we may be certain as to the exact truth of the pa- 
tient's statement. 

Children and deaf-mutes sometimes state that they 
hear the watch, both when the repeater has been touched 
and when it has not. There are also cases where the 
patient is not able to distinguish the ticking of the 
watch from the tinnitus aurium, and he thus gives very 
confusing answers as to the distance at which the watch is 
heard. 

Sometimes it is not unimportant to know that most 



EXAMINING THE AMOUNT OF HEARING. 25 I 

watches have a clearer tone immediately after they have 
been wound, and, on the other hand, that the tone is 
somewhat softer just after they have been cleaned by a 
watchmaker. 

However, setting aside all these possible means of 
arriving at false conclusions, the watch alone does not 
afford a sufficient means of determining the amount of 
hearing of the person examined, because the distance at 
which it can be heard does not always stand in proper 
proportion to the power of understanding conversation. 
You will quite often find a case where the patient is 
able to hear conversation of a low tone, quite a consi- 
derable distance, and yet can only hear the watch when 
pressed on the ear; and then, again, you will find the 
state of things reversed, that is, he understands conversa- 
tion with great difficulty, while the watch can be heard 
when it is held some distance from the ear. Such a mis- 
proportion, we find, sometimes takes place when other 
circumstances which may render a correct judgment diffi- 
cult, such as a peculiar mode of speech, foreign dialect, 
and want of intelligence, are entirely wanting. 

As a general thing, persons who have become hard of 
hearing in childhood, hear the watch better than conversa- 
tion; and, on the other hand, those whose deafness has 
begun later in life, are less prevented from hearing conver- 
sation than from hearing the watch. 

There are, however, not unfrequently, exceptions to this rule, and 
some that are very striking. Thus, I saw a sad case, where an ex- 
tremely intelligent man, a little more than forty years of age, who 
had become deaf only a short time before, was so to such a de- 
gree that he could not hear conversation, even through a speaking 
tube. He was also extremely short-sighted, an added misfortune, 
since all communication with him must be by writing. He could hear 
a repeating watch, however, very well, when laid upon the auricle of 
one ear, and one inch from the other. (I have seen persons who were 



252 EXAMINING THE AMOUNT OF HEARING. 

not at all troubled in hearing ordinary conversation, and who were 
not aware that their hearing was impaired, who could hear an ordi- 
nary ticking watch only at a short distance, much less than that at 
which it was heard by many patients who come under treatment on 
account of loss of hearing. St. J. R.) 

We may explain some cases of this kind by remember- 
ing that an adult is more accustomed to understanding 
conversation than the child, and that therefore it is easier 
for him. Yet, at other times, this explanation is not suffi- 
cient, and you will often find that a patient hears his own 
voice and that of the surgeon, immediately after the intro- 
duction of the catheter, much more distinctly, while he 
cannot hear the watch any further, and possibly less. 
Strange as this may seem, I have observed it in many- 
cases, occurring in undoubtedly trustworthy patients, and 
I have satisfied myself, by various experiments, of the 
truth of their statements. The cases which verified these 
observations were those of young persons between the ages 
of seventeen and twenty, and where there were decided 
adhesive processes on the membrana tympani. After the 
artificial membrana tympani has been applied, it is not a 
rare occurrence that the patient hears conversation mark- 
edly better, while the watch is not heard so well as before. 

You see, then, gentlemen, what a one-sided opinion you 
will give as to the hearing of your patient, and as to the 
benefit of treatment if you rely upon the watch alone 
as a test of hearing. You must then make a closer exa- 
mination, by testing the power of hearing the voice and 
conversation. While one ear is being examined as to this, 
the other should be closed by the finger of the patient, 
and you should speak slowly and distinctly, at first in a 
whisper; for instance, count, towards the side of the pa- 
tient, varying from a loud to a soft tone, at different dis- 
tances, or, if necessary, talk through a speaking tube, and 



EXAMINING THE AMOUNT OF HEARING. 253 

cause the patient to repeat word for word, after you, what 
is said. You must guard against any deception, by seeing 
that the patient does not practice the habit of watching 
the mouth of the speaker. Almost all patients who are 
hard of hearing, if they are not also myopic, very soon 
accustom themselves to watching the mouth of the 
speaker, looking always directly at it, in order to improve 
their understanding of what is half heard by seeing the 
motion of the lips. Most patients acquire the habit un- 
consciously, and, without knowing the reason why, attempt 
to get opposite the speaker, and look at his face. 

Thus, you will often be informed by a patient, as some- 
thing very peculiar, and as an undoubted proof of nervous 
deafness, that he hears much worse by twilight and at night 
in bed, than when it is light about him. This is only a 
natural result of the fact, that such patients do not have 
the benefit of sight to aid their hearing. 

Women, especially, accustom themselves to this habit 
of watching the mouth, and, added to it, are such adepts 
in guessing, that although entirely deaf, they can hold a 
conversation for hours with their neighbor in society, with- 
out being disturbed on account of not hearing. Proper 
names and bearded men are an abomination to these ladies, 
for it is through them that their often carefully concealed 
infirmity comes to light. 

If, then, in many deaf persons, the power of hearing 
the tick of a watch, and understanding conversation, 
stand in such an evident misproportion to each other, 
there are various explanations for it which, perhaps, for 
the greater part, rest on varied acoustic principles. This 
is not the place to go very extensively into the subject; I 
will only further remark, that there is a great difference 
between hearing conversation and understanding it. A great 
many patients will tell you that they are aware of the 
carrying on of a conversation, at a considerable distance 



254 EXAMINING THE AMOUNT OF HEARING. 

from them, but it is only at a much shorter distance that 
they are able to tell what is said. 

Besides, the tick of a watch has only one tone, or 
at the most two tones of a certain hight, while it often 
seems to occur exactly in the case of deaf persons, that 
some tones, or some classes of tone, which correspond to 
a certain tone hight, or number of vibrations, are entirely 
out of reach of the hearing, or can only be appreciated in 
a considerable increase in the strength of the sound. 
Thus, there are patients who hear deep tones proportion- 
ably better than high ones. Generally, however, the 
reverse is true, and tones which correspond to an excessive 
number of vibrations in a given time, as, for example, the 
voices of females and children, are proportionately better 
heard, even when the tones are not very strong. The lat- 
ter is, however, generally the rule. Deep tones must be 
proportionately stronger in order to be heard equally well 
with high ones. As is well known, the voice of a basso 
must have a greater intensity — be stronger than that of the 
tenor, if he wishes to fill the opera house as well. 

In hearing, moreover, it is not only a matter of inten- 
sity of the tone, and the number of vibrations in the 
second, but of the speediness of the tones in following 
each other, and the space between the individual tones. A 
measure of the hearing, which shall answer all indications, 
and possess any practical value, must carry all these various 
points into view, and must also be conveniently and easily 
used. 

Try, gentlemen, if you, with the aid of a mechanic, at 
once educated in physics and music, may not be able to 
construct such an instrument. The acoustic apparatus 
now to be found in physiological cabinets, such as the 
Sirene, do not answer our purpose, at least so far as I have 
been in a position to test them. Perhaps such an instru- 
ment can be constructed after the manner of a music box, 



EXAMINING THE AMOUNT OF HEARING. 255 

or hand organ; since in these there are a number of notes 
in a cylinder, of the same hight of tone, which, by means 
of a simple contrivance, can be made to move with varied 
swiftness, and in various degrees of vibration. 

Yet we need not continue this subject at too great a 
length. As insufficient as the watch is, we have as yet no 
better measurer of hearing, but we should never forget 
that we must always examine as to the power of hearing 
conversation. When a repeating watch is not enough to 
.show us if there is still hearing power, we may use a hand 
bell, ringing it behind the head of the patient. 

Von Conta 1 recommends, instead of measuring the distance at 
which a watch is heard, that a tuning fork, immediately after it has 
been caused to vibrate, should be placed at the end of a diagnostic 
tube (Toynbee's otoscope), which has previously been placed in the 
ear, and the number of seconds counted during which its vibrations 
may be heard. 

Deaf persons very often tell you of hearing better in the 
midst of noise and roaring sounds. Misapprehension, and 
lack of proper observation, are generally at the basis of 
these statements. When a noise takes place about us, we 
unconsciously raise our voices, so that the patient, who 
is less disturbed by it than we, has the benefit of this 
elevation of voice for his less susceptible ear. Many 
patients say they hear much better when riding in the cars, 
and the explanation of it must must be the one given 
above. Besides this, the narrowness of the room, and 
the closeness of the speakers to each other, should be 
considered. 

Some persons, who at other times hear very well, have 
great difficulty in understanding what is said while riding 
in a wftgon, so that a deaf person, who is accustomed to 

1 Archiv fur Ohrenheilkunde, 1, s. 207. 



256 EXCESSIVE ACUTENESS OF HEARING. 

hearing with difficulty, and with close attention, has then 
some advantage. I have never heard of any patient, how- 
ever, who could hear a watch at a great distance under 
these circumstances. 

Yet, there are a number of observations on this subject 
which cannot be so summarily dismissed. Thus, Willis 
(in 1680), tells of a man who could only converse with 
his deaf wife while a servant was beating a drum. This 
rare symptom received the name paracusis Willisiana. 
Fielitz also 1 speaks of a boy, the son of a shoemaker, who. 
could only hear the words spoken in the room when he 
stood near his father, who pounded sole leather on the lap- 
stone. Whenever the father wished to speak to him, he 
took the hammer and pounded the leather. The boy also 
heard very well in the midst of the sound of a mill, but 
outside of it he could not. 

These are, however, rare instances, and we may ask our- 
selves if similar symptoms may not arise when there is a 
partial separation of the connection between the ossicula 
auditus, in the cavity of the tympanum, for instance, of 
the stapes from the incus. Loud sounds, such as have 
been just mentioned, would force the membrana tympani 
inward, and thus approximate a union of the severed con- 
nection of these two bones. If such a case occurs to you, 
it would be well to try the effect of the celebrated wad of 
cotton. 

Excessive acuteness of hearing. — When we speak of 
a morbid acuteness, or fineness of hearing, we mean an 
abnormal sensitiveness of the ear to all sharp, shrill tones 
and loud noises. This is present in certain irritated con- 
ditions of the brain, in the various acute and chronic 
inflammatory affections of the deeper parts of the ear, and 
also when a sudden change from hardness of hearing of a 

1 A. G. Richter's Chirurg. Bibliothek. B. ix, st. 3. s. 555. 



CONDUCTION OF SOUND THROUGH BONES. 257 

high grade, to normal hearing power occurs, as, for exam- 
ple, after removing inspissated cerumen from the ear, 
which has been in the meatus, and impaired the hearing 
for years. 

Conduction of sound through the bones of the head. — 

By this we understand that sort of conduction of sound 
to the organs of hearing, which occurs when we bring fixed 
sonorous bodies immediately in contact with the head. 
Some writers on aural surgery proceeded from the incor- 
rect idea that the bones alone took part in such a conduc- 
tion of tones, and that the whole of the remaining 
sound conducting apparatus of the ear — the auditory 
canal, membrana tympani, and cavity of the tympanum, 
with all its contents — was excluded, especially if the meatus 
were stopped up. They considered themselves to be justi- 
fied in deciding, from the existence or non-existence of 
the power of hearing a watch laid upon the bones of the 
head, whether the auditory nerve, with its expansion into 
the labyrinth, were in a normal or diseased condition. 

The premises are incorrect, and consequently the con- 
clusions. They are detailed by some writers at great 
length. The view above given depends upon a misappre- 
hension, and one-sided estimation of what was said by 
E. H. Weber and J. Miiller on this subject. The latter 
named author very clearly stated, 1 that we are not able to 
decide how great the conductive power of the bones of 
the head alone, for sonorous waves, which are communi- 
cated to them from the air, or from fixed bodies, may be, 
because the increase in the conducting power from other 
sources, and the resonance of the parts belonging to the 
ear alone, can not be excluded. 

If a vibrating body be brought in contact with the 
bones of the head, vibrations are, of course, conducted 

1 Handbuch der Physiologie, II Bd., 1840, s. 455. 

33 



258 PERCEPTION OF SOUND THROUGH BONES. 

immediately from the fixed parts to the labyrinth; first to 
the lamina spiralis ossea of the cochlea, as being the part 
of the nervous labyrinth which stands in immediate con- 
nection with the bones. Another part of the vibrations, 
however, which are conducted to the labyrinth, are those 
which are first brought upon the membrana tympani and 
the ossicula auditus. 1 



E. H. Weber first enunciated the idea (1834) that the membrana 
tympani and ossicula must also vibrate in the conduction of sound 
through the bones of the head. The experimental proof was furn- 
ished very recently by A. Lucae. 

It is only recently that aural surgeons, A. Lucae and 
Politzer, have made the conduction of sounds through the 
bones the object of a strictly scientific investigation. 1 
The latter, especially, attempted to render the subject a 
practical one, in the diagnosis and prognosis of aura 
disease. 

We cannot here go into a consideration of all the ques- 
tions arising on this point, since many of them are not 
yet fully settled, and the complication of the experiments 
causes some of the results to seemingly contradict each 
other. 

For the purpose of testing the perception of sound 
through the bones, we should use a watch having a loud 
tick, as well as a strong toned tuning fork. It will be 
better to employ several of the latter, of different tones. 
For the purpose of testing with the watch, it is laid on 
the temples and the mastoid process, while the patient 
gently closes each auditory meatus. If the tick cannot 
be heard on either side, the watch is taken between the 
teeth. 

1 Lucac, Virchow's Archiv., B. xxv and xxix. Mediz, Central Blatt, 1863, Nos. 40, 41 : 
1865, No. 13. Archiv fur Ohrenhelkunde, 14. Po/itzer, A. F. O., I and 4. Mach y 
Wiener Akad, Sitzungs Bericht, 1863, '64, '65. 









USE OF THE TUNING FORK. 259 

After the tuning fork is set in vibration, by striking it, 
its handle is placed on the median line of the vertex of 
the head, and the patient is asked in which ear he hears 
better. If the answer be undecided, the handle of the vi- 
brating tuning fork is placed at the center of the upper 
row of teeth. 

The fact which has been for a long time well known, that 
the tone of a watch or tuning fork held on the bones of 
the head or on the teeth, is immediately heard better if the 
auditory canals are closed without any pressure, should be 
considered as the point from which all conclusions must 
come as to the practical value of the conduction of sound 
through the bones of the head (Knochenleitung) . 

Very different explanations have been given to the facts 
already observed by E. H. Weber, The most valuable 
and practical are those of Mach (referred to in the note on 
the preceding page). According to this author, the tones 
are increased in strength, because the sonorous waves are 
prevented from being softened or dissipated by passing 
out of the ear. 

(We must accept the view, that when the sound passes 
from the air through the membrana tympani and ossicula 
to the labyrinth, that it must again pass out, in part at 
least, by the same way.) 

The same effect that is produced in a physiological ex- 
periment by stopping up the meatus with the finger, is 
caused in a patient with aural disease, by any abnormity 
in the sound conducting apparatus. Just as any hindrance 
to the conduction of sound makes the entrance of tones 
into the ear difficult, so does it prevent the breaking up or 
dissipation of the sonorous waves, if they are carried to 
the ear, by the bones of the head. They must then be 
carried to the expansion of the auditory nerve in the laby- 
rinth in double strength, as long as this part possesses a 
normal power of receiving sounds. 



260 USE OF THE TUNING FORK. 

Those vibrations, especially, that are carried by the 
bones of the head upon the membrana tympani, and 
ossicula, must be prevented — if certain anomalies of ten- 
sion and mobility of these parts exist — from being re- 
flected outward, and must therefore be conducted with 
double power inward, through the fenestrae to the labyrinth. 

Patients with stoppage of the meatus (by cerumen, a 
foreign body, furuncular inflammation), alterations in the 
tension and thickness of the membrana tympani (from 
closure of the tube, myringitis), or in whose middle ear 
the air encounters resistances (e. g., by a collection of 
mucus or pus in the ossicula, by their rigidity, or by 
relaxation or thickening of the membranes of the fenes- 
trae), if the affection be in one ear only, or of differ- 
ent degrees in the two ears, and there is no abnormal 
condition of the labyrinth, are able to hear a tuning fork 
placed on the median line of the vertex of the head, bet- 
ter in the affected ear than in the other. If this state of 
things does not exist, or if the patient hears the tuning 
fork better in the normal or least affected ear, we may con- 
clude with some probability, that there is a lessened per- 
ceptive power in the expansion of the auditory nerve in 
the labyrinth. A further observation and analysis of the 
case will then decide whether we should consider this ab- 
normal condition in the internal ear as a primary or 
secondary affection. If it be the latter, it proceeds from 
a disease of the cavity of the tympanum. It may then be 
a temporary abnormal pressure on the membranes of the 
fenestrae by a fluid secretion, or a permanently increased 
intra-auricular pressure, such as often depends on a fixed 
and abnormally deep position of the base of the stapes. 
A diminution of the sensitiveness of the nervous appa- 
ratus to sounds, may, however, result from a long con- 
tinued absence of every perception of sound. 

You see, gentlemen, that valuable assistances, not only 



PERCEPTION OF SOUNDS THROUGH THE BONES. 26 1 

to the diagnosis, but also the prognosis in individual cases, 
may be obtained from the estimation of the degree of the 
perception of sounds through the bones of the head. 
These should be taken advantage of in chronic catarrh of 
the middle ear, wherever the worse ear does not hear better 
when the watch is placed on the bones, for this is a disease 
exceedingly varied in its symptoms, and in which it is ex- 
ceedingly difficult to make a prognosis. Politzer very 
properly calls our attention to the fact that this symptom 
should never be viewed by itself, but in connection with 
others, especially with the course and duration of the dis- 
ease, as well as the kind of tinnitus aurium which may exist. 
One of the objections to this mode of examination is, 
that we must be contented in using it, with the evidence, 
and the talent for observation which the patient may be 
able to give and which he happens to possess. This latter 
is sometimes surprisingly small. Some patients cannot 
tell that they hear on one side better than the other, even 
if it be so. It is, therefore, very often necessary to urge 
the patient to make an unprejudiced investigation, and to 
explain the method to him, and at least, to repeat the 
experiments several times. 

Politzer says, in a letter to me, that in cases where the patient is 
not able to state at all correctly in which ear he hears the tuning fork 
better, he places both ends of a single otoscope (or diagnostic tube) 
in the auditory canals, and that then the sensation is more decided. 

For the objective examination as to the degree of the 
passage of the sound from one or the other ear, Politzer 
recommends an otoscope (or diagnostic tube), of two feet 
in length, which is placed in both auditory canals. From 
the center of this passes a gutta-percha tube of one foot 
long, communicating with the caliber of the otoscope. 
Lucae used for the same purpose a double otoscope, made 
like the double stethoscope of Scott Allison. 



262 USE OF THE TUNING FORK. 

While the tuning fork, which has been placed in vibra- 
tion, is on the vertex of the head, or on the teeth of the 
patient, we may by alternately pressing the two arms pass- 
ing to the patient's ear, determine from which ear the tone 
is coming, and also distinguish the difference in its magni- 
tude and clearness. Care should be taken that the tuning 
fork is vibrating fully, and that the two ends of the three 
armed tube are evenly placed in the meatus. Politzer calls 
attention to the fact that even in those who hear normally, 
differences in the strength of tone with which a tuning 
fork placed on the bones of the head is heard, may be at 
times perceived. These may depend upon an unequal 
width of the auditory canal. The same author shows 
that the results of this method of examination have, up 
to the present time, not been entirely satisfactory. 

I should still say to you that Lucae lays a great weight 
upon the fact of the better hearing power of a patient, if 
it so happen that he does hear better, when the watch or 
tuning fork is placed on the bones, while the auditory 
meatus is closed. He says that in the cases where no im- 
provement occurs we must conclude that there is some 
impediment that prevents the membrana tympani from 
becoming tense in an inward direction, and the stapes from 
exerting pressure upon the contents of the labyrinth. 
According to Lucae the increase in the strength of the 
tone, when the auditory meatus is secluded, depends upon 
the increase in the intra-auricu|^r pressure. 

The power of perceiving sounds through the bones is 
much less in advanced age than earlier in life. We can 
therefore draw no direct conclusions from a want of hear- 
ing the watch or tuning fork after a patient is over fifty 
years of age. 

Lucae has recently described a new method of examin- 
ing the organ of hearing for physiological and diagnostic 
purposes, with the aid of the " interference otoscope. " 



INTERFERENCE OTOSCOPE. 263 

By this name he designates the double otoscope described 
above, but altered in such a manner that an india-rubber 
tube is inserted in it, which leads to a small metal sound 
receiver, of the shape of a half paraboloid. The latter is 
brought in front of a tuning fork placed on an isolated 
stand, and this is struck by means of a small wooden ham- 
mer. By alternately pressing together one and the other 
tube of the double otoscope we may decide how much the 
sonorous waves are reflected from each ear. This reflec- 
tion of sounds increases in all changes in the sound-con- 
ducting apparatus, which either directly or indirectly cause 
an increased tension of the membrana tympani. 

By this objective examination of the reflective power of 
the ear we may gain assistance for determining how far 
anomalies of the sound-conducting apparatus, not recog- 
nizable with the catheter and ear mirror, may cause the 
impairment of hearing, or we may determine if disease of 
the labyrinth exists, in which latter case no great reflection 
of the sonorous waves conducted into the meatus will 
occur. 



LECTURE XVII. 

SIMPLE ACUTE AURAL CATARRH 

Different forms of catarrh of the middle ear; acute catarrh, 
its symptoms and consequences; treatment. 

Gentlemen: We come to-day to the diseases of the 
middle ear, and first to the inflammations of its mucous 
membrane. Catarrh of the middle ear may be designated 
as either simple or purulent, and each of these varieties 
may have an acute or a chronic form. 

An inflammation of the periosteum of the middle ear, 
spoken of by several authors as an independent and pri- 
mary affection, hardly occurs, any more than a periostitis 
of the external auditory canal, of which we have previously 
spoken. It is anatomically impossible to divide the lining 
of the middle ear into mucous membrane and periosteum. 
How, then, can we distinguish different affections of this 
membrane? Here, still more than in the bony part of the 
external auditory canal, each intensive inflammation of 
the integument must bring with it disturbance of the 
nutrition of the bone lying beneath, for the membrane 
which we are accustomed to call mucous is at the same 
time the carrier of the vessels for the bone; it is also peri- 
osteum as well as mucous membrane. Every inflammation 
of the mucous membrane lining the cavity of the tym- 
panum and the mastoid process, is also an inflammation of 
the periosteum; every catarrh of this membrane is a peri- 



ACUTE CATARRH OF THE EAR. 265 

ostitis. If the inflammation be chronic in its course, 
thickening of the mucous membrane and hypertrophy of 
the bone, hyperostosis, more easily occurs; while in acute 
processes, as is well known, the mucous membrane inclines 
more to ulceration, and periostitis leads to atrophy of 
the bone, inflammatory softening, and superficial caries. I 
have often seen diseases of the bones of the middle ear as 
the result of very acute, or long existing inflammation of 
its soft parts. On the other hand I have observed no dis- 
ease that seemed to certainly indicate an independent and 
primary periostitis. 

Acute catarrh of the ear. — We may employ this ex- 
pression for the sake of brevity, since the middle ear is 
the only part of the organ covered by mucous membrane, 
and consequently the only one affected with catarrh. It is 
characterized by hyperaemic swelling of the whole mucous 
tract of the middle ear, with great increase of secretion, 
which has chiefly a mucous character. It is a much more 
rare form of disease than the chronic variety. 

I have hitherto observed these cases mostly in the early 
spring, or late in the fall. They generally occur from 
some definite cause, for instance, after cc catching cold," 
from getting the body very wet, and generally in con- 
nection with catarrhal inflammations of the nasal pass- 
ages or fauces, or with bronchial catarrh or inflammation 
of the lungs. The lower portion of the Eustachian 
tube is involved in nearly every severe cold in the 
head, or naso-pharyngeal catarrh. From such a mild and 
generally temporary form of circumscribed acute aural 
catarrh, or, if you please, tubal catarrh, in persons espe- 
cially predisposed, or from some new exciting cause, an 
extensive and severe form of the affection may arise. It 
may be said, in general, that persons inclined to inflamma- 
tions of mucous membranes are very apt to have inflam- 

34 



266 ACUTE CATARRH OF THE EAR. 

mations of the middle ear. We therefore often find the 
acute form arising in many cases, when the patients have 
been suffering for a long time from the chronic form. 
Most of the cases that I have observed have been those 
where the patient has suffered for a long time from deaf- 
ness of one side, in consequence of chronic catarrh, and 
the hitherto healthy ear was then attacked with the acute 
disease. A person who, to all appearances, had heard well, 
certainly well enough for all his ordinary duties, suddenly 
became, at one stroke as it were, limited to hearing only 
the loudest sounds. I have observed these cases especially 
often among men in middle life. They often result from 
the extension of a secondary syphilitic eruption of the mu- 
cous membrane of the pharynx and tongue. In severe 
cases the aural catarrh usually affects one side only, but on 
close examination you will scarcely ever find the other ear 
entirely free from disease. 

The impairment of hearing is generally of a high de- 
gree. Not rarely it is nearly absolute as regards common 
conversation. The loss of hearing generally occurs quite 
suddenly, and is consequently the more marked; and yet 
the patient will often remember that some time before the 
sudden seizure he had noticed a slight occasional diminu- 
tion of his sharpness of hearing. With the deafness 
the patient sometimes experiences nothing more than 
a feeling of pressure and fullness in the ear. Much more 
commonly, however, there is in the first stage of the affec- 
tion, severe pain, referred to the deep parts of the ear, 
sometimes lasting only a night, and occasionally some 
days, with few intervals, and always exacerbating at night. 
This causes so much loss of sleep that it pulls the patient 
down very rapidly. The pain is not increased by pulling 
upon the meatus auditorius externus, or by pressure in the 
region in front of the ear; but it is increased by swallow- 
ing, or by any motion of the jaw, or general movement 



ACUTE CATARRH OF THE. EAR. 267 

of the head. In one case every swallow of cold water 
caused so much pain that water and other fluids were 
warmed before they could be used. This pain is often 
accompanied by toothache, and it must be here stated that 
pain in the molar teeth is often hard to distinguish from 
pain in the middle ear. In severe cases the pain will be 
referred to the mastoid process, and this will be found sen- 
sitive to any considerable pressure, even when no external 
evidences of disease can be discerned. The pain gene- 
rally runs over the whole side of the head, being more 
severe in the front part, in the region of the frontal sinus. 
Noises in the ear are scarcely ever wanting. They form 
part of the greatest trouble of the patient, on account of 
the great hammering and pounding going on there. One 
patient said it seemed to him as if an empty barrel were 
struck upon close to his head. The patients are much 
disturbed by these sounds, and are often in doubt if they 
are not real ones that are being made near them. 

Add to all this, that such patients have an intense 
heaviness in the head; that they not unfrequently suffer 
from vertigo, even when they lie quietly in bed; that 
febrile symptoms of variable degree scarcely ever fail, 
which increase in the evening almost to delirium, and 
you will more easily understand how it is that those 
persons, who a few days before were not disturbed in the 
least in understanding all that was said, and not at all hin- 
dered in their daily occupation, now bear in their faces the 
picture of the most intense anxiety, as with wide-open 
eyes they listen for each word which has no sound for 
them, and look around in great loathing and disquiet to see 
whence comes this constant noise, reduced and excited as 
they are by fever, pain, anxiety and loss of sleep. 

You will understand, I say, how the patients give you 
the impression that they are suffering from cerebral or 
mental disease. You need not be surprised that acute 



268 ACUTE CATARRH OF THE EAR. 

catarrh of the ear is sometimes called meningitis, or acute 
congestion of the brain, especially when the pain in the 
ear has become so extended as no longer to be locally dis- 
tinguished, or when the deafness on the one side escapes 
notice, and thus the attention of the surgeon is in no 
respect turned to the ear. 

I can assure you that many persons have come to me 
with " nervous deafness" induced by an inflammation of 
the brain, according to the statement of their physicians, 
when an examination of the ear showed that the impaired 
hearing was in consequence of acute catarrh of the cavity 
of the tympanum. 

It is especially difficult, in the case of children, to distin- 
guish acute aural catarrh from a congested condition of the 
brain. It seems probable to me, from some anatomical 
facts, which I shall lay before you in the course of these 
lectures, that purulent catarrh occurs very often in children, 
and that its symptoms are very often misunderstood. 

You remember, from our anatomical studies, the con- 
nection existing between the vessels of the cavity of the 
tympanum and of the dura mater, formed by means of a 
branch of the arteria meningea media passing through the 
petro-squamosal fissure. Every peculiar attack of ver- 
tigo and irritation of the membranes of the brain, so fre- 
quently observed in inflammation of the cavity of the 
tympanum, especially in acute catarrh, may depend in part 
at least on this anatomical condition. It is also possible 
that some of these symptoms may be indications of con- 
secutive hyperemia of the labyrinth. 

It is more probable, however, that they are due to 
increased intra-auricular pressure, from the pressure upon 
the fenestras, dependent either upon congestive swelling of 
the membrane, or upon secretion collected in the cavity 
of the tympanum. 

If we examine the ear during an attack of acute catarrh, 



ACUTE CATARRH OF THE EAR. 269 

we find the external auditory canal wholly unaltered, if we 
except an increased redness close to the membrana tym- 
pani. In trivial cases this only appears as a light tinge of 
red mingled with the grey color of the membrane. This 
depends upon the injection of the mucous membrane, and 
of the whole structure of the cavity of the tympanum, 
which has an influence upon the color of the thin and 
transparent membrane. In the most hyperaemic stages 
the membrana tympani usually appears very brilliant. 
This brilliancy causes the very red transparent mem- 
brane to look like a polished copper plate. (Politzer.) 
Soon, and sometimes immediately, the brilliancy of the 
outer surface is lessened, or even removed. It ceases to 
reflect the light evenly in some portions in consequence of 
its infiltration, and thus the triangular light spot, which we 
are accustomed to see on the membrana tympani, at the 
anterior and lower portion, can no longer be discerned, or 
is seen very indistinctly. The handle of the malleus, in 
all cases where the outer surface of the membrane is not 
much affected, remains plainly visible, and this is a point 
which helps us in our diagnosis, for in. such a case, the sit- 
uation of the affection must be deeper than the surface of 
the membrana tympani. In severe cases, however, in con- 
sequence of the greater infiltration of the epidermis and 
cutis, we can no longer see the handle of the malleus. 
The vessels running over it are seen filled with blood, so 
that we have a red line in the middle of the membrane, 
running from above downward. The surface of the drum 
appears dull, of a bluish grey color. Sometimes minute 
vessels are seen in the periphery of the membrane. In 
some places the curvature or plane of the membrane is 
altered, either in consequence of the increased secretion 
pushing it forward, or of different degrees of swelling of 
the various parts. 

The discoloration of the membrana tympani frequently 



270 ACUTE CATARRH OF THE EAR. 

varies in the different parts of the membrane; for example, 
it may be of a reddish grey color in the upper part, while 
in the lower half it is greyish yellow or yellowish white. 

The appearance of the parts varies, of course, in accord- 
ance with the severity of the attack, and with the amount 
of the changes in the mucous membrane and the mem- 
brana tympani, that have previously existed. Thus, the 
hyperaemia of the cavity of the tympanum, and of the 
inner surface of the membrana tympani, will not appear 
where the thickening of these membranes has occurred 
as a result of previous inflammation. In cases where a 
long continued chronic catarrh suddenly increases, which 
may be called sub-acute catarrh of the cavity of the tym- 
panum, all these symptoms will be less prominent, and the 
disease will resemble an exacerbation of a severe chronic 
catarrh. 

We are not always able to tell in the very first stages of 
the affection, whether we are dealing with an acute catarrh 
of the cavity of the tympanum, or an acute inflammation 
of the membrana tympani, i. e., myringitis. The impair- 
ment of hearing is generally much greater in the former 
variety of disease, and it is generally improved, or the 
other symptoms relieved, by the forcing in of air. Be- 
sides, in acute aural catarrh there are usually catarrhal 
symptoms in the naso-pharyngeal space. 

If we examine the ear in the later stages of the affection, 
the membrana tympani does not appear to have lost so 
much of its brilliancy; the triangular light spot is changed, 
generally lessened in size, however. It is at times only a 
point. It is very rarely diffused over the whole surface 
without any distinct borders. The membrane is usually 
somewhat opaque, of a dull lead color, and occasionally 
it has a moist look, and here and there, perhaps, a white 
or yellow appearance is mingled with the dull grey color. 
It will only be found to be injected along the handle of 



ACUTE CATARRH OF THE EAR. 271 

the malleus, which is distinct, although often very much 
drawn inward. It is abnormally concave as a whole, and — 
apart from some partial irregularities in its curvature — 
there is often seen a band running backwards and down- 
wards from the short process of the malleus, which may 
account for the abnormal concavity. 

I have never seen any considerable redness or swelling 
of the external parts in the vicinity of the ear during the 
affection; at the most they are somewhat tender on press- 
ure. We find, however, that the throat participates in the 
attack, there being always a severe injection of the mucous 
membrane of the pharynx. There is generally pain and 
difficulty in swallowing, stuffing of the nasal meatus, dry- 
ness of the mouth, and other catarrhal symptoms. Many 
patients complain of crackling sounds towards the ear at 
every motion of swallowing, accompanied by variations in 
hearing and in the feeling of the ear. Such patients 
nearly always complain of a hollow sound of their own 
voice, which symptom is particularly marked on closing 
the unaffected ear. After the pain and the febrile symptoms 
have disappeared, the heavy feeling in the ear and in the 
head, and deafness, still remain for some time. The 
crackling and whistling sound in the ear occurs more fre- 
quently, and the patient always has the hope that some 
time, sooner or later, the loud report, so famous for being 
the prelude to restoration to hearing, will occur, and that 
he will then be well again. It is really true that we may 
occasionally observe a case where a patient hears a loud 
report in his ear during sneezing or yawning, and that the 
hearing is greatly improved after it. Sometimes the hear- 
ing is gradually improved without any such report. In 
many other cases, however, in spite of general treatment, 
it remains for months and years the same, until at last the 
catheter is introduced. Morbid changes on the mem- 
branes of the fenestrae not unfrequently occur from such 



272 AURAL CATARRH PROGNOSIS. 

an acute catarrh, which we are not able to lessen unless the 
patient comes under treatment at an early stage, and thus 
an incurable obtuseness of hearing may remain. 

Prognosis. — In acute catarrh of the cavity of the tym- 
panum without suppuration, the prognosis is, to a certain 
extent, favorable. It is certainly only with an entirely 
inappropriate treatment that a deeper seated affection 
occurs. The slight impairment of hearing, which is all 
that usually results, may be generally improved by an early 
local treatment. The reason that perforation of the mem- 
brana tympani is comparatively rare in this affection, is, that 
there is more tendency to thickening and swelling than soft- 
ening and deliquescence of tissue. Perforation may occur, 
however, if poultices are used very much in the treatment. 

Just at the beginning of a very severe case, where exu- 
dation follows very rapidly, or after blowing the nostrils, 
or a severe fit of sneezing, a small rupture of the mem- 
brana tympani sometimes occurs, with a slight amount of 
bloody serous discharge. As a rule, the edges of this per- 
foration unite very quickly, so that on the next day the 
rent is usually closed, and the further course of the affec- 
tion is not different from a simple acute catarrh. 

There is, however, a somewhat unfavorable view in 
the prognosis arising from the fact that relapses often 
occur. Still more frequently there remains an unmis- 
takable tendency to continuous chronic catarrh of the 
ear. We may very often observe cases where persons 
who have once suffered from an acute catarrh of the ear, 
and who again acquired a good hearing power, after it had 
subsided, become deafer and deafer as years pass on, with- 
out any sudden change in the hearing at any one time, or 
without acute inflammatory symptoms of any sort. In 
some cases this state of things occurs in sub-acute stages. 
Very many patients whose hearing is impaired will recol- 



ACUTE AURAL CATARRH PROGNOSIS. 273 

lect such acute attacks, that made them perfectly deaf for 
a time, as having occurred in early life. They recovered 
their hearing, to a certain extent, through constitutional 
treatment, without any local treatment whatever. In the 
course of time such patients may, very gradually, become 
very hard of hearing. 

These facts may be explained in a two-fold manner. 
On the one hand, as experience tells us, every person who 
has suffered once from a severe catarrh of any organ, 
remains for a long time especially predisposed to an affec- 
tion of the same part. There is, on the other hand, 
an anatomical reason for the explanation of such cases. 
Among the most frequent consequences of such an acute 
catarrh of the ear, are permanent thickening of the mucous 
membrane lining the middle ear, as well as various forms 
of adhesions and attachments which are developed from 
the contact of the two surfaces which existed at the time 
of the acute inflammation. These adhesions most fre- 
quently connect those parts of the middle ear which are the 
least distance apart in a normal condition of things. Such 
connections occur most commonly between the membrana 
tympani and promontory, between the same membrane 
and the incus, or the membrana tympani and the head of 
the stapes, and still more often between the two niches 
of the fenestra ovalis and rotunda; in one place con- 
necting the walls of the cavity with each other, in another 
with the stapes. 

. It is clear that when such adhesions have taken place, 
and the space of the cavity is so much diminished, each 
swelling of the mucous membrane, such as occurs with 
every cold in the head, is at least of some importance. 
Each congestion of the membrane, however slight, which 
could produce no effect upon a normal cavity, in one that 
has been narrowed as above described, will diminish the 
sharpness of hearing in a sensible degree. In the same 

3S 



274 ACUTE AURAL CATARRH PROGNOSIS. 

way, the parts already abnormally approximated are 
brought still nearer, until every angle and space is filled. 

Furthermore, every thickening of the membrane of the 
tube, and anomaly in its secretion, are of especial im- 
portance, because they greatly favor the occurrence of sub- 
sequent closure of the tube. If in consequence of such 
acute inflammation of the glandular layer of the tube, an 
hypertrophy occurs, and the sub-mucous tissue becomes 
thickened, while at the same time the glands incline to 
secrete a tenacious thick mucus^ the power required of the 
muscle to open the tube is increased. These muscles 
finally become unable to overcome the constantly increas- 
ing resistance. Thus the regularity in the opening of the 
tube necessary to insure a normal condition of the ear is 
very easily and frequently impaired. 

It is also to be conceived that such abnormal attachment 
and adhesions, even if of themselves they do not impair 
the hearing a great deal, constantly exercise a bad effect 
upon the parts, by keeping up a state of irritation. Thus, 
without any further exciting cause, they become the basis 
of a constantly occurring condition of local congestion. 
As is well known, such a state of things occurs in the eye, 
when adhesions have occurred between the iris and the 
capsule of the lens, in so-called posterior synechia. 

When such adhesions exist in the eye, irregularity of 
action and tension occur during the act of accommodation 
of vision for different distances, and at every movement 
of the iris, which always lead to relapses and renewed 
attacks of iritis. 

What was once explained as resulting from a "rheumatic 
diathesis," may now be referred to a purely mechanical 
cause, since the first inflammation left a permanent source 
of irritation, from which a constant influence is excited on 
the iris. There is a similar condition of things in the ear, 
even if we are not correct in ascribing a certain amount of 



ACUTE AURAL CATARRH TREATMENT. 275 

accommodating power to the stapedius and tensor tym- 
pani muscles. Still their presence and muscular struc- 
ture give evidence that they are the source of motion to 
the parts upon which they act. These motions must cer- 
tainly be irregular, and inharmonious, if the parts to be 
acted upon are confined by adhesions. 

We may assert that a congested condition may be main- 
tained by such synechias, in the ear as well as in the eye, and 
made the basis of repeated attacks of imflammation. As 
each iritis which leaves behind a synechia, retains a tend- 
ency to a return of the inflammation, and to formation of 
new adhesions, so we must believe that each catarrh of the 
cavity of the tympanum will more or less affect the ear 
injuriously at a later period, and that irritation will be 
more apt to occur in proportion to the number of adhe- 
sions left behind. 

It follows from the foregoing that the results of treat- 
ment will depend upon our ability to prevent permanent 
thickening of the mucous membrane, and adhesion of its 
various parts with each other. 

Treatment. — We shall best accomplish the results de- 
sired, if the catheter be introduced as soon as possible, and 
air forced through it into the cavity of the tympanum. 
Following the advice of the authors, I formerly delayed 
the introduction of the instrument until the acute inflam- 
matory symptoms had disappeared, lest I should excite 
pain, and do injury to the parts. I have satisfied myself 
by many experiments, that it is not at all necessary to 
wait so long, and that we shorten the inflammatory pro- 
cess by introducing the catheter. I have sometimes intro- 
duced the instrument at a time when the membrana 
tympani was greatly injected, and the patient had intense 
pain in the ear. Instead of an increase of pain from the 
introduction of air, the patient always found it lessened, 



276 ACUTE AURAL CATARRH TREATMENT. 

if not at the very moment, at least in a short time after. 
In short, he began to improve from that time. Not 
unfrequently the pain ceased after the catheterization, or 
a very great improvement of the hearing resulted, even 
when the sensation of the patient, and auscultation and 
examination of the drum showed that the air did not enter 
the cavity of the tympanum, but that the tube was simply 
rendered pervious. 

Recall the condition of the ear during the inflammatory 
process, and you may explain this. The membrane is 
everywhere swollen, the secretion greatly increased. This 
secretion fills the cells of the mastoid process as well as 
the cavity of the tympanum, and it cannot find exit, be- 
cause the Eustachian tube, which is of the same structure, 
is affected in the same manner, and its swollen walls pre- 
vent the egress. If we reopen this passage by a vigorous 
blowing in of air, some of the secretion will yield, the 
pressure will be removed from the walls of the cavity of 
the tympanum, and especially from the susceptible mem- 
brana tympani. It is on this membrane that the chief 
symptoms of pressure will be felt, and when it is relieved 
much of the congestion and inflammation will also be 
removed. 

1 

Very recently 1 Scbwartze recommends paracentesis of the 
membrana tympani, in the cases of collections of mucus 
in the cavity of the tympanum so large as to cause a 
bulging outward of the drum. According to Schwartze's 
observations this bulging outwards occurs most frequently 
in childhood. Since the secretion rapidly reaccumulates, 
the paracentesis should be repeated. No considerable in- 
flammatory reaction is said to follow such a repetition. 
Scbwartze considers this treatment as one more certainly 
adapted to prevent the changes ordinarily arising from 
acute aural catarrh than the employment of the air bath 

1 Archiv fiir Ohrenheilkunde, II, IV, s. 264. 



ACUTE AURAL CATARRH TREATMENT. 277 

through the catheter. Of course when the patient is in a 
very excitable or febrile condition from constitutional dis- 
ease, we should not immediately attempt the introduction 
of the catheter, which may then seem to the patient a for- 
midable operation. In such cases Politzer's method 
furnishes a very welcome substitute for it. Any great or 
sudden pressure of air is to be avoided during the acute 
stages of the disease; we may therefore force in the air 
through a tube of gutta percha, by means of the mouth, 
instead of using the india rubber air bag. Any sort of a 
tube will do, in case of necessity, instead of a rubber one. 
We may employ local blood letting in the first stages, 
whether we are able to use the catheter or not, with a 
cathartic of calomel and jalap, 2-3 grains of the former, 
with 5-8 of the latter, in a powder, of which 46 may 
be taken during twenty-four hours. Four to six leeches 
may be applied, part of them just anterior to, and partly 
just under, the external meatus. The severe pain will 
generally cease with this treatment; when it does not 
the ear may be filled every hour with warm water, which 
the patient allows to remain in about fifteen minutes. 
The patient should remain in bed, and gentle diaphoresis 
be produced (with aq. acetat. amm. in tablespoonful 
doses). We must look after the catarrhal symptoms of 
the fauces and nose, and as soon as motions of the throat 
can be borne, let the part be gargled with an infusion of 
marsh mallow, to which a little borax is added. A little 
later on an astringent gargle may be employed. It has 
been sometimes advised to give an emetic in these cases, 
especially tartrate of antimony and potash, or an agent 
that will cause sneezing, in order that by means of the 
severe shaking of the head, through the vomiting or 
sneezing, the mucus may find its way more easily through 
the Eustachian tube. Such a strong impression as is pro- 
duced by severe sneezing or vomiting, may have a some- 



278 ACUTE AURAL CATARRH^ — TREATMENT. 

what dangerous effect on the membrana tympani — its 
rupture might be easily caused. The introduction of the 
catheter, or the use of Politzer's method, is certainly not 
accompanied by as much danger, and their effect is more 
easily regulated. If the acute stages be once passed, the 
treatment is no different from that of chronic catarrh, of 
which we shall speak in the next lecture. 

(I am obliged to dissent from that part of the treatment 
of acute aural catarrh, as advised by the author in the 
foregoing pages, which speaks of the use of calomel and 
jalap. I regard the use of these powerful agents as wholly 
unnecessary in this class of cases. I would rely upon the 
leeching, the use of diaphoretics of various kinds, and 
gargles, in connection with the practice of filling the ear 
with warm water. The use of Dr. E. H. Clark's aural 
douche will be found a convenient and pleasant means of 
treatment. (See fig. 12, page 95.) If necessary a mild 
cathartic may be given, but if the attack has not been pre- 
ceded by constipation, I can see no advantage in the use 
of active cathartic remedies. It is well known that our 
treatment of acute disease of the eyes has been much 
simplified in the past few years by abstaining from the free 
use of mercury, counter irritation, etc., in the various 
forms of ophthalmia. My experience seems to teach me 
that we may in like manner simplify the treatment of 
acute aural disease with success. 

The effect of leeches in acute aural catarrh, in relieving 
the agonizing pains that usually accompany it, is almost 
magical. I have seen very many cases that have been 
treated for days by ear drops, and blisters, with absolutely 
no benefit, until the patients were nearly exhausted with 
pain, and in which the application of one or two leeches 
on the tragus has caused relief in a very few minutes. 
The remedy is somewhat troublesome, but in case the use 
of the warm douche does not soon relieve the pain, I 



ACUTE AURAL CATARRH TREATMENT. 279 

know of no substitute for leeches. Besides their value to 
overcome the acute symptoms, they prevent the unpleasant 
consequences that have been so graphically described in 
the foregoing pages. Turkish and Russian baths are 
recommended by Dr. Agnew, of this city, in the acute 
stages of aural catarrh. St. J. R.) 



LECTURE XVIII. 

SIMPLE CHRONIC AURAL CATARRH. 

Its varieties; sclerosis; catarrh of the tube, and true catarrh 
of the middle ear; pathological anatomy; course and subjec- 
tive symptoms; some peculiar "nervous" symptoms; an 
attempt to explain them. 

Gentlemen: We shall consider to-day the chronic 
form of non-suppurative, or simple aural catarrh. Like 
all inflammations, chronic catarrh of the mucous mem- 
brane of the ear sometimes affects the interior of tissue, 
that is, it is interstitial, and thus chiefly produces a thick- 
ening and loss of elasticity of the tissue. 

Again, it is chiefly characterized by hyperaemic swelling, 
and abnormally increased secretion, with consequent thick- 
ening, hypertrophy of the mucous membrane. 

We may then divide chronic aural catarrh into two great 
varieties, and the latter form — true or moist catarrh — 
into two sub varieties. 

The one form affects the Eustachian tube principally, 
gradually narrowing it, and frequently closing it entirely. 
The other shows itself chiefly by hyperaemia, and swell- 
ing of the membrana of the cavity of the tympanum. 

(The three forms, then, may be classified as follows: 

i. Sclerosis of the mucous membrane of the middle 
ear. 

2. Catarrh of the Eustachian tube. 



CHRONIC AURAL CATARRH PATHOLOGY. 28 I 

3. True catarrh of the cavity of the tympanum. St. 

J- R-) 

Each of these forms may occur independently of each 
other. More frequently, however, they cannot be accu- 
rately distinguished, but are combined with each other. 
It will be better, therefore, not to speak of each form 
separately. 

Having thus premised that these varieties of the affec- 
tion exist, we may say in a general way, that chronic aural 
catarrh consists of a repeated swelling, with gradual thick- 
ening of the mucous membrane lining the middle ear, 
which morbid process generally takes place during a stage 
of great congestion, and is usually accompanied by in- 
creased secretion. 

Pathology. — Before we pass on to speak of the symp- 
toms and course of this form of disease, I may attempt 
to briefly describe the pathological conditions which result 
from it, so far as we have learned them by investigations 
on the dead subject. We have, however, not yet reached 
any satisfactory stage in our knowledge of the pathology of 
chronic aural catarrh, but we must characterize the condi- 
tion of things in this department as only initiatory. It is 
only a short time since it was even attempted to place our 
knowledge of diseases of the ear on an anatomical basis. 
Until quite recently the greater number of aural affections 
that were not suppurative, and all forms of deafness which 
did not depend on some affection of the external auditory 
canal, which we now consider as consequences of chronic 
catarrh of the middle ear, were characterized as "nervous 
affections of the ear." 

In this extremely convenient view, any investigation on 
an anatomical basis, that is, by an examination of the 
parts on the cadaver, was of course regarded as superflu- 
ous. This having been the state of things, it is not sur- 

36 



282 CHRONIC AURAL CATARRH PATHOLOGY. 

prising that our knowledge and ideas of the morbid 
charges in chronic aural catarrh are still in a somewhat 
crude condition, that they are chiefly confined to what 
may be observed with the naked eye, and that we do not 
yet properly understand the finer changes in the tissue of 
the middle ear. The muco-periosteal lining of the osseous 
middle ear, which for the sake of brevity we call a mucous 
membrane has as yet received no complete microscopic 
examination as to its condition in a state of health. 

I would suggest this labor to one of you, as the subject 
of an inaugural thesis for the degree of doctor of medi- 
cine. It is a work whose performance is much to be 
desired. 

We know the least about that form which we describe 
as an interstitial process, as a dry catarrh (if I may use 
the term), or as sclerosis of the mucous membrane of the 
middle ear. These names accord with a practical need of 
distinguishing certain forms of aural disease which we must 
refer to morbid processes in the middle ear, from the 
ordinary form of aural catarrh. It is possible that an 
extension of our knowledge of this form, founded on an 
anatomical basis, would give it an independent position in 
the classification of aural disease. 

This sclerosis is a pathological process, in which the 
mucous membrane becomes denser, more rigid and ine- 
lastic. These changes impair the vibratory power of the 
membrana tympani very much, and of the membranes of 
the fenestra rotunda, and fenestra ovalis. They finally 
lead to complete rigidity, calcareous or osseous degenera- 
tion of the membrane surrounding the stapes, anchylosis 
of the stapes, or of the membrane of the fenestra rotunda. 

We do not yet know certainly whether calcareous de- 
posits, or other molecular changes constitute the basis of 
this condition. The alterations may possibly be chiefly 
periosteal, accompanied by the formation of exostosis, or 






CHRONIC AURAL CATARRH PATHOLOGY. 283 

perhaps be dependent on shrinkage of a tissue that was 
previously hyperaemic and relaxed. 

We are better informed as to the changes which the 
true, or moist chronic catarrh of the cavity of the tym- 
panum may produce. In recent cases these changes are 
hyperaemic swelling, and hypersecretion of the mucous 
membrane. In old cases the very thin and transparent 
covering of the middle ear becomes of a whitish or bluish 
gray color, more or less thickened, and at the same time 
its surface, as well as the interior of its tissue, are very 
vascular. 

At times there is the same condition of the mucous 
membrane in all the structures and walls of the cavity of 
the tympanum. Again, the vascularity is more decided 
on one part than another. Thus, cases occur where there 
is only hypertrophy of the mucous fold of the mem- 
brana tympani, while in other parts the cavity is in a 
normal condition. The membrana tympani may, on the 
other hand, be in a completely healthy condition, and the 
hypertrophy be confined to the membranes of the fenestras. 
The whole of the mucous membrani is, however, more 
frequently affected. 

We may now look a little more in detail at the changes 
that may occur on the various parts of the cavity of the 
tympanum. The general thickening of the mucous mem- 
brane is very frequently extended to the articulations of 
the ossicula auditus, especially to the articulation of the 
malleus and incus. 

The articular capsule becomes gradually thicker and 
thicker, and thus the mobility of the articulation is 
affected. It may at last become fully destroyed, and 
the joint become anchylosed. Just as often the band by 
which the head of the malleus is fastened to the roof of 
the cavity of the tympanum (Jig. suspensorium cap. mallei) 
becomes hypertrophied. An abnormal fixation of this 



284 CHRONIC AURAL CATARRH PATHOLOGY. 

part, and by subsequent shrinkage, an abnormal position 
of the malleus occurs, which again exert an influence upon 
the vibratory power of the membrana tympani. The 
same changes in the tendon of the tensor tympani muscle 
exert similar influences on the malleus and membrana 
tympani, stretching their attachments and changing their 
position. This tendon, while it is attached to the neck of 
the malleus, has not only a mucous coating of its own, 
but is extensively connected, especially anteriorly, with the 
adjacent mucous membrane. 

Among the more important parts which may be drawn 
into participation in such a chronic catarrhal process, the 
fenestra rotunda and fenestra ovalis should be especially 
mentioned. We not unfrequently find the small bony 
canal, or the niche, over whose extremity the mem- 
brane of the fenestra rotunda is stretched, covered by a 
more or less rigid pseudo-membrane, or its mucous mem- 
brane is hypertrophied, and thus the canal or niche is 
narrowed. It may be even completely filled by thickened 
and vascular mucous membrane, as well as by a plug of 
connective tissue. 

In the same manner the membrane of the fenestra ro- 
tunda itself, the so-called membrana tympani secondaria 
becomes thickened. Perfect calcareous degeneration of 
this membrane may also occur. Similar changes take place 
in the niche or depression for the stapes, and the mem- 
brane surrounding the fenestra ovalis and the base of the 
stapes. This membrane, like the covering of the fenestra 
ovalis, has a delicate coating from the mucous membrane 
of the middle ear. 

Sometimes the stapes is fixed in one direction or the 
other by abnormal ligaments, or even by little osseous 
connections. Again, it is immovably fixed in a proliferat- 
ing mucous membrane, or in a mass of rigid connective 
tissue. In other cases the annular ligament surrounding 



CHRONIC AURAL CATARRH PATHOLOGY. 285 

the base of the stapes is thickened, or even entirely calca- 
reous. All these conditions must greatly impair the func- 
tions of this important terminal extremity of the chain of 
bones, as well as the conduction of sound to the labyrinth. 

The above described alterations in the fenestra ovalis and 
rotunda, belong in part to the adhesive processes in the 
cavity of the tympanum, of whose occurrence we have 
already spoken. Such an abnormal attachment of parts, 
that were previously disconnected, results not only in con- 
sequence of acute catarrh, but it may also be gradually de- 
veloped in the course of cases of the chronic variety. If 
thee ongestive swelling be very great, or if the process be 
attended by suppuration, these attachments may become 
very extensive. Extensive synechias of the membrana 
tympani are found to be especially frequent, as a conse- 
quence of catarrhal affections which have occurred during 
childhood. 

I may here speak of the more or less extensive pseudo- 
membrane and neoplastic formations developed from 
swollen mucous membrane, which occur in various parts 
of the middle ear, for example, between the membrana 
tympani and the different walls of the cavity; between 
the tendon of the tensor tympani and the ossicula auditus; 
between the latter and the walls, as well as between the 
individual bones themselves. Such adhesions fill up the 
spaces and angles of the cavity, and put one or the other 
part in an abnormal state of tension. The cavity of the 
tympanum itself may be obliterated by the development 
of masses of connective tissue. It may be even divided 
into separate parts by these partition-like adhesions. In 
view of the great variety of such conditions as have been 
just enumerated, it is scarcely worth while to describe them 
any more exactly, since each post mortem examination 
may exhibit a new variety. 

We may best observe the great variety of these adhe- 



286 CHRONIC AURAL CATARRH PATHOLOGY. 

sions, by the examination of a number of anatomical 
preparations, such as I am able to show you 1 in quite a 
variety. 

Fig. 28. 




Sieglfs aural speculum. 

Siegle's aural speculum sometimes enables us to see these adhesions 
very distinctly. This ingenious contrivance consists of a speculum 
whose external opening is wide, and covered by glass, and which has 
an india rubber tube connected to it laterally. The speculum is 
introduced into the meatus so as to hermetically close it. The air is 
then exhausted by suction upon the gutta percha tube, while at the 
same time the movements of the membrana tympani are observed 
through the glass. 2 

I may only briefly state, that when such adhesive pro- 
cesses are very extensive, that the tendon of the tensor 
tympani muscle, or the articulation between the incus and 
stapes is almost always involved. These parts, by their 
position, favor the formation of such abnormal adhesions. 

When we come to speak of pharyngeal catarrh we may 
describe the various conditions that obtain in catarrh of 
the Eustachian tubes. I need only state here that this 
morbid process shows itself by closure of the tube, and 
with it of the whole middle ear. The air in the cavity of the 
tympanum, the mastoid process, and in the osseous part 
of the tube, is shut off by this closure, while absorption 
from the moist mucous membrane and its blood vessels 1 

1 Virchow's Archiv, B. XVII, 51-80. Toynbee's Descriptive Catalogue of Preparations, 
illustrative of diseases of the Ear. London, 1857, I. 

a Deutsche Klinik, 1864, No. 34. Archiv fur Ohrenheilkunde, 1, s. 79. 



CHRONIC AURAL CATARRH PATHOLOGY. 287 

still goes gradually on. It is thus, of course, at length 
rarefied. The membrana tympani, which, in a normal con- 
dition of things, lies between two strata of air of equal 
density, is now more pressed upon by the stratum in the 
auditory canal. It finally yields and sinks inward. The 
first link in the chain of ossicles is attached to the mem- 
brana tympani. The whole chain, exactly like the drum, 
is soon pressed inward, and the stapes communicates the 
pressure to the contents of the labyrinth, which is also in 
a state of abnormal pressure from the long continued clos- 
ure of the Eustachian tube. The chief characteristics of 
this condition are change in the relative position of the 
membrana tympani, and of the stapes, so that both lie 
farther inward towards the fluid of the labyrinth. We 
may artificially produce this state of things by closing the 
mouth and nose, and swallowing several times. We thus, 
in a measure, exhaust the air from the cavity of the tym- 
panum. We soon observe a certain sensation of fullness 
and pressure in the ear, together with a certain amount of 
tinnitus and loss of hearing. 

Closure of the tube, with its results, are observed in pa- 
tients in the same way, although less noticed on account 
of their gradual occurrence. The symptoms just enumer- 
ated may be observed at every cold in the head, and 
every severe bronchitis. If the swelling of the mucous 
membrane only lasts a short time, the ear, as a rule, 
perfectly recovers its functions as soon as the equilibrium 
of air, before and behind the membrana tympani, is re- 
stored. 

This is apt to occur during sneezing, blowing the nose, 
or yawning, and is made evident to the patient by a crack- 
ing sound in the ear. In yawning vigorously the pterygo- 
maxillary ligament is rendered tense. This is a smooth, 
roundish string of connective tissue, which passes close to 
the mucous membrane, is covered by it, and extends from 



288 CHRONIC AURAL CATARRH PATHOLOGY. 

the pterygoid process to the lower extremity of the lower 
jaw, and is thus connected to the mucous membrane of 
the tube. After the equilibrium is restored the patient 
hears as, well as before, and is freed from the pressure, full- 
ness, and noise in the ear. If, however, the closure of the 
tube, with its consequences, have existed for months and 
years, if the membrana tympani, with the ossicula auditus, 
have been for some time pressed against the vestibule, and 
thus pressure has been exerted upon the delicate structure 
of the labyrinth, structural changes must occur in all the 
parts involved, including the tensor tympani and stapedius 
muscle. These effects are permanent, and do not disap- 
pear even when the causes are removed, and the connection 
between the pharynx and the cavity of the tympanum is 
restored. 

Politzer has called attention to a very important consequence of 
long continued closure of the tube, "secondary retraction of the tendon 
of the tensor tympani muscle" If the membrana tympani be greatly 
pushed inward, the attachment of the tendon on the handle of the 
malleus must approach the inner wall of the cavity of the tym- 
panum. The tendon that was formerly tense, now becomes relaxed, 
and since the antagonistic power of the tendon — the tension of the 
elastic membrane — is partially removed by the outer pressure of air, 
the shortening must occur in the same way, in order to serve as a 
balance ; just as contraction of the tendons of the leg results if the 
knee has been for a long time bent. " Of course such shortening of 
the tendon, when it lasts for some time, will increase the bulging 
inward of the membrane. Even if the tube becomes again permea- 
ble, it must act with an abnormal amount of traction exerted from 
within. It is very easy to see how impairments on function of vary- 
ing degree may thus occur." 

Tenotomy of the tensor tympani may be thought of for such 
cases. It would be by no means difficult to perform this operation. 
Hyrtl, 1 " with decorous reserve," mentions it as possibly being a 
remedy for some forms of deafness. 

» Topographische Anatomie, I, sec. 1 54. 



CHRONIC AURAL CATARRH SYMPTOMS. 289 

Subjective Symptoms. — The prominent subjective 
symptom is impairment of hearing. In many cases this 
is accompanied by disturbing sensations. 

The latter are not unfrequently so insignificant in 
chronic aural catarrh, that the patient is not able to state 
with any definiteness how many years it is since his affec- 
tion began. The disease shows itself only by its conse- 
consequences. There is an impairment of hearing that 
has occurred very gradually, and increased so slowly that 
the patient's attention is first called to it when it has 
reached such a degree as to interfere with the proper per- 
formance of his duties. Such cases, where the attention 
of the patient is not called to his affection by pain, tinni- 
tus, or any other abnormal sensation, but only by a slowly 
increasing loss of hearing, have been most frequently con- 
sidered as cases of nervous deafness. It is only possible 
to learn the true nature of the affection by an exact exa- 
mination of the parts, and especially of the membrana 
tympani. The form denominated sclerosis of the middle 
ear is especially characterized by an insidious and slow 
course. At the most it is accompanied in the later stages 
by very severe tinnitus aurium. 

The amount of impairment of hearing in individual 
cases does not so much depend on the extent of the 
thickening of the mucous membrane of the cavity of 
the tympanum, as upon the situation of such an alter- 
ation of tissue. A slight loss of elasticity in parts 
that assist materially in the conduction of sounds to the 
labyrinth, especially in the membranes of the two fenes- 
tras, will impair the acuteness of hearing much more than 
even a very great change in the membrana tympani, or in 
other parts of the walls of the cavity. Hence it is, that 
we so often find the hearing so little impaired in many 
cases where great alterations have occurred in the mem- 

37 



290 CHRONIC AURAL CATARRH SYMPTOMS. 

brane of the tympanum. It is shown by manifold obser- 
vations that very high degrees of impairment of hearing, 
almost amounting to perfect deafness, may occur solely 
from changes in the cavity of the tympanum, that is in 
the sound-conducting apparatus. 

In recent tubal catarrh, besides the impairment of hear- 
ing, for external sounds, increased resonance of the pa- 
tient's own voice is often complained of. If only one 
tube be closed, the tuning fork will be heard more power- 
fully in the affected ear, or in it alone. 

The more, on the whole, the Eustachian tube is in- 
volved in the morbid process, the more variations do we 
find in the hearing and feelings of the patient. 

In very many cases one subjective symptom — noise in 
the ear — is present in connection with the slowly increas- 
ing deafness, and it often forms the chief source of the 
complaints of the patient. The pain which occurs in 
chronic aural catarrh is generally of short duration, appear- 
ing only when the patient is exposed to severe cold, or to 
a draught of wind. It is described as a biting, gnawing 
pain, and soon passes away. Frequent attacks of pain, 
lasting for some time, are indications of sub-acute stages of 
the disease. In such cases we are especially apt to find 
partial thickenings, formations of striae, in the cavity of 
the tympanum. Very acute pain may occur in acute 
closure of the tube, together with decided changes of an 
adhesive nature. 

The patients often complain of pressure in the ear, of a 
feeling as if the ear were "stopped up," of fullness and 
heaviness in it. These symptoms appear generally in 
the morning on awaking. It is a characteristic symptom 
of chronic catarrh, that patients complain that in the 
morning, after having slept very long, they feel an in- 
creased heaviness in the ear, and greater impediment of 
hearing. On the other hand, the tinnitus almost always 



CHRONIC AURAL CATARRH SYMPTOMS. 29 I 

increases in the afternoon, and after dining. Many- 
are very much disturbed from sleep on placing the head 
on the pillow, by sounds which do not trouble them when 
up and about. The feeling of fullness and heaviness in 
the ear that has been mentioned, increases in many patients 
with the slightest causes which produce a congestion of the 
head, or which check the passage of blood from it. We 
find, then, that after drinking wine, or strong tea, after 
bending over at work, as, for instance, at the writing desk, 
or embroidery frame, or when the patient is, from any 
cause, bodily or mentally fatigued, that this feeling of full- 
ness and heaviness appears. In teachers and preachers the 
deafness and tinnitus increase very markedly after long 
continued speaking. 

The influence of temperature is greatly felt in these 
cases. Such patients hear best in a cold, dry season ; and, 
on the contrary, the hearing power is much diminished in 
cold and wet weather, or in very severe summer heats. 
Sudden changes of temperature always have an unpleasant 
effect on these cases. The patients then complain of hearing 
sounds as if muffled, if they pass from cold air into warm, 
but if from warm to cold, they sometimes speak of slight 
pain being occasioned. The noises in the ear are not 
heard so much in free, fresh air, as in a closed room, 
especially in one that is overheated. A number of these 
subjective symptoms depend on the chronic, irritated con- 
dition of the nasal passages and fauces, and the reflex 
action of such a state upon the Eustachian tube. 

In connection with the sensation of pressure and heavi- 
ness in the head, which may at times extend to attacks of 
vertigo and vomiting, many patients say that the increase 
of the affection of the ear has rendered them less capable of 
intellectual labor. Every long continued fixation of the at- 
tention to one point, wearies them so that they are obliged 
to desist. This symptom is seen in people who were pre- 



292 CHRONIC AURAL CATARRH SYMPTOMS. 



TSP 



viously able to read and write for hours without any sense 
of weariness or oppression, but who, now, cannot continue 
any such employment but for a short time. Patients 
often express their symptoms by saying that thinking has 
become hard for them — they feel as if pressure were made 
upon the brain, or as if it were in motion. A young 
physician afflicted with this disease, said to me, "I can't 
grasp an idea any more." In many cases, after long con- 
tinued and severe mental labor, these symptoms of full- 
ness and pressure increase to a severe pain in the head, 
which troubles the patient more than the impairment of 
hearing, and other symptoms. 

Other patients, and also those who are not at all, at least 
to any sensible degree, disturbed in their hearing power, 
speak of an unusual irritableness, of being suddenly and 
without reason overcome by very sad thoughts and forebod- 
ings, which sometimes increase to weeping. For a long time 
I considered these last named symptoms as only accidental, 
and merely noted them in my history of cases, until their 
frequent recurrence suggested to me that they were of 
some importance. They were present, not only in sensi- 
tive females, but also in the most clear-headed and strong- 
minded men. The connection of these symptoms with 
the affection of the ear was also established, in my mind, 
by the fact that after a purely local treatment they dis- 
appeared, and that they appeared in regular order, with a 
relapse of the affection. It is especially to be noticed in 
such patients, that some forms of headache confined to 
one side of the head, are diminished, or entirely disappear 
during the use of the air douche. 

In individual cases the symptoms of nervous irritation, 
particularly the great noise in the head, and vertigo, which 
may increase to the vomiting of the food, and then to 
that of a bilious and slimy substance, are so prominent 
that the ear is not recognized as the point of origin, even 



♦ 
CHRONIC AURAL CATARRH SYMPTOMS. 293 

by the most accomplished physicians. These attacks are 
then considered as consequences of acute congestion of 
the cerebrum. A case of this kind, observed by myself 
and others for more than a year, showed me to what an 
extent these symptoms may go. In this case, on one occa- 
sion, after several days of severe tinnitus, attacks of verti- 
go occurred which lasted for fourteen hours. At first they 
were accompanied by vomiting, and afterwards by a con- 
tinual sense of nausea and choking. The seizures were 
usually less severe than this, but when the Eustachian 
tube remained for several days. impermeable to the Valsal- 
vian experiment, or Politzer's method, a gradually increas- 
ing pressure in the head, noise, and great increase in the 
impairment of hearing occurred just before the attacks of 
vertigo. The patient could induce slight symptoms of 
this nature by pressing his finger strongly into the meatus 
of the affected side. It was interesting to notice that the 
patient, who was affected by a severe chronic pharyngeal 
catarrh, and who had, at every swallowing motion, a sensa- 
tion " as if a valve opened and shut," had no trace of this 
sensation as soon as the noise in the ears began. The walls 
of the tube did not then open. 

Such cases, although not usually so severe as the one 
just mentioned, are not very rare. Whenever attacks of 
vertigo occur quite frequently, the ear should be examined. 
The impairment of hearing is frequently confined to one 
side, and thus it may easily escape notice. 

(I have observed two striking cases of this sort, one 
that of a gentleman engaged in active business pursuits, 
whose hearing was affected on one side alone. A course of 
treatment by means of the Eustachian catheter relieved 
the vertigo, but the impairment of hearing was only very 
slightly benefited. The other case is that of a lady almost 
totally deaf on one side, while the other ear is but slightly 
i affected. The attacks of vertigo, accompanied by nausea 



294 CHRONIC AURAL CATARRH SYMPTOMS. 

and vomiting, are very unfrequent. This case is still 
under treatment, and has been benefited. St. J. R.) 

The question now occurs, how may we explain these 
symptoms last described, to which the general name of 
"nervous symptoms" is apt to be given. We may also 
ask, how may they be referred to the changes in struc- 
ture which are known to occur in chronic catarrh of the 
ear? 

Some of these disturbances of sensation may be best 
referred to a simultaneous affection of the adjacent nasal 
cavities, while others may be considered as reflected neu- 
ralgia, conveyed from the nerves of the cavity of the 
tympanum — the tri-facial, glosso-pharyngeus, sympathetic 
plexus, or from the otic ganglion, to other nerve tracts. 

The severe forms, however, of these nervous symptoms, 
especially the attacks of vertigo and vomiting, must be 
referred to pressure and irritation of the labyrinth-in- 
crease of the intra-auricular pressure. Long continued 
closure of the tube, with alteration in the position of the 
drum, or the stapes, or even pathological changes in the 
fenestra ovalis or rotunda, hyperemia, swelling and thick- 
ening of their membranes, all of these may, under certain 
conditions, produce such symptoms of irritation of the 
internal ear. 

In the lecture on nervous diseases of the ear we shall 
detail the physiological experiments which prove that great 
irritation of the semi-circular canals will produce impair- 
ment of coordinate movements, uncertainty in walking 
and standing. It is about the same whether these irrita- 
tions have their origin in the membranous semi-circular 
canals themselves, or if they are caused by causes acting 
secondarily upon them. The latter is the case in severe 
pressure upon the base of the stapes, since this acts di- 
rectly upon the vestibule in which all the semi-circular 
canals open. 



CHRONIC AURAL CATARRH SYMPTOMS. 295 

Since disturbances of the proper relative position of the 
membrana tympani and stapes, as well as abnormal con- 
ditions on the fenestral membranes, occur much more fre- 
quently than the symptoms of irritation of the internal 
ear that have been described, we must inquire into the 
particular conditions necessary to produce these symp- 
toms. Anchylosis of the articulation of the malleus and 
incus, or complete want of elasticity of the membrane of 
the fenestra rotunda, n.iay play a prominent part in pro- 
ducing them. The former condition may produce this 
effect, because no movement of the articular surfaces 
is possible, and thus excessive pressure exerted upon 
the drum is directly transmitted from the malleus to the 
stapes. The latter prevents the yielding of the fluid of 
the labyrinth, and thus the pressure must act more power- 
fully upon the contents of the vestibule and the semi- 
circular canals. Besides, the attachment of the stapes to 
the fenestra of the vestibule should be extremely free, 
perhaps, even, extremely relaxed. The case that I have 
just related went to sustain this view, because when the 
attacks of vertigo did not occur, the hearing was very 
little impaired for conversation. The patient had previ- 
ously had typhus fever, and was for a time deaf on both 
sides. On the one side the hearing improved considera- 
bly, but changes may have remained in the cavity of the 
tympanum which would favor these irritations of the 
internal ear, if the tube were closed for a long time. How 
much sclerosis of the mastoid cells, with great lessening 
of their capability of containing air, may contribute to 
the same result, we shall see at a later period. 

Of course much will also depend on the nature of the 
person affected, and the general irritability of the cerebral 
nervous system. The mechanical irritation required to 
produce great symptoms of reaction, is naturally much 
less with a person of diminished powers than in a patient 
where the nervous center has great capabilities of resistance. 



LECTURE XIX. 

CHRONIC NASO-PHARYNGEAL CATARRH AS ONE OF THE SYMP- 
TOMS OF CHRONIC AURAL CATARRH. 

The anatomical and physiological connection between the ear 
and pharynx; relations of the muscles of mastication to the 
ear; rhinoscopy and the pathological appearances in the naso- 
pharyngeal space; a case of formidable rusty-colored expecto- 
ration from the pharynx ; symptoms of chronic pharyngeal 
catarrh ; nerve supply of the pharynx. 

Gentlemen: Having just attempted to describe the 
pathological changes in the ear, caused by chronic catarrh 
of that organ, as well as the important consequences of 
the disease, I consider it advisable to undertake an exa- 
mination of the chronic affections of the mucous membrane 
of the superior and inferior pharyngeal space, before we 
pass on to the diagnosis and the objective symptoms of 
chronic aural catarrh. 

If you should at first be inclined to consider this change 
of subject abrupt or premature, you will soon see the 
great importance of affections of the pharynx to the ear, 
and the close connection of the two parts to each other. 

In most cases of aural disease you should never omit 
to examine the mucous membrane of the nose and pharynx. 
You will very often find these parts affected, and very 
differently in different cases of chronic aural catarrh. 

The affection of the ear frequently proceeds from a 
morbid condition of the naso-pharyngeal cavity, or at 



STRUCTURE OF THE PHARYNX. 297 

least is kept up by the latter. Until very recently the 
greater number of writers on aural disease denied the ex- 
istence of this connection between aural and pharyngeal 
catarrh. I confess, for myself, that I consider it entirely 
unintelligible that this connection can be held in question 
when a considerable number of intelligent and unpreju- 
diced patients, without being asked, speak of the depen- 
dence of the one inflammatory process upon the other, 
and when, also, the anatomical facts, physiological laws, 
and the results of treatment, confirm the same view. 

The development, as well as the structure of the Eus- 
tachian tube, prove that its mucous membrane is a con- 
tinuation of that of the pharynx. At the lower part of 
of its pharyngeal orifice, especially, it has exactly^the same 
anatomical characteristics. It is thick, puffy, vascular, 
and contains a number of mucous glands, whose mouths 
we may generally see very plainly with the naked eye. 
The lower part of the mucous membrane of the tube, 
which passes without any distinct line of demarkation into 
that of the pharynx, is generally in the same condition 
with the latter, and participates in all its congestive and 
inflammatory conditions. Any considerable affection of 
the mucous membrane in the lower section of the tube, 
must necessarily extend to the upper parts of the ear in 
a purely mechanical way. The narrowing of the tube thus 
caused — a tube which is normally very narrow, and which 
very readily closes up, especially in the upper portion — 
will at once shut up the secretions of the cavity of the 
tympanum, and thus place this part in an abnormal con- 
dition. In addition to this, the cutting off of the com- 
munication between the cavity of the tympanum and the 
pharynx, as well as the gradual absorption of the air which 
remained in it at the time of the closure, will render the 

38 



298 PHARYNGEAL CATARRH. 

pressure of the air on the membrana tympani unequal. 
There will only be pressure from the side of the external 
meatus, and thus this membrane, as well as the whole 
chain of the ossicula auditus, are forced abnormally inwards. 

Catarrh of the pharyngeal extremity of the tube must 
then always affect the condition of the parts of the ear 
lying above and beyond, even where they do not them- 
selves participate in the inflammatory process. 

In a similar and purely mechanical way, thickening of the 
uvula, which is often increased to double its normal size 
in chronic pharyngeal catarrh, acts upon the pharyngeal 
orifice of the tube. The anterior lips of the tube are 
pressed against the posterior by such a lifting up of the 
velum, and thus its pharyngeal opening is greatly nar- 
rowed. Enlarged tonsils produce the same effect, al- 
though not directly, as has been often asserted, but the 
mouth of the tube may be displaced by a lifting up of the 
posterior arch of the palate, or of the whole uvula. In 
some cases the posterior extremity of the inferior turbi- 
nated bone is raised in consequence of hypertrophy, as 
high as the anterior lip of the tube, and may also partially 
displace it. 

Such conditions appear to occur at times in an acute form, in con- 
sequence of an increased flow of blood to the head; for example, 
after a full meal, or after drinking alcoholic stimulants. This may 
be explained by the rich supply of this part of the mucous membrane 
with venous blood. 

Just as often, at least, pathological conditions of the 
naso-pharyngeal space are continued along the Eustachian 
tube. A catarrh of the cavity of the tympanum often ex- 
ists in connection with a pharyngeal or nasal catarrh. 

This is particularly shown by examination on the dead 
body. On recent subjects we often find the whole mucous 
membrane of the middle ear, at the same time with that 



CONNECTION BETWEEN PHARYNX AND EAR. 299 

of the pharynx, in a state of congestive swelling, hyper- 
emia, and hyper-secretion. The appearance of the differ- 
ent parts will vary, in accordance with the difference in 
structure. The mucous membrane at the tympanic orifice 
of the tube most resembles that of the pharynx, and of 
the lowest cartilaginous portion of the tube. At that 
point, that is, in the immediate vicinity of the membrana 
tympani, and at the transition of the tube to the cavity of the 
tympanum, the lining membrane, which in the bony portion 
is thin, pale, and without glands, becomes for a little dis- 
tance much thicker and vascular, and has also some quite 
large-sized, grape- shaped mucous glands. The swelling 
and hyperemia are naturally not so evident in the remain- 
ing portion of the Eustachian tube, and in the cavity of 
the tympanum itself, but they may be plainly seen, how- 
ever, in the most of cases, even in those parts. 

Daily observation and practical experience show us that 
neighboring mucous membranes belonging to one system, 
are almost always in a similar normal or morbid condition. 
Johannes Miiller says: "The mucous membranes have a 
great tendency to communicate their affections along their 
course. 1 We see, therefore, that affections of the mucous 
membrane are often extended per continuitatem" Catarrhal 
inflammation of the conjunctive and lachrymal sac occur 
from coryza, and the inflammation of the buccal cavity, in 
typhus fever, extends through Wharton's duct, to the little 
glandular canal of the parotid. 

It is well known that constitutional diseases — I will 
only name typhus fever, tuberculosis, and the acute exan- 
themata — very often extend themselves from the pharynx 
to the mucous membrane of the ear. 

While we are speaking of the connection between 
pharyngeal and aural affections, we should remember that 

1 Hand-Buch der Physiologie, 1844. 



300 CONNECTION BETWEEN PHARYNX AND EAR. 

the muscles which move the palate, and assist in swallow- 
ing, are also muscles of the Eustachian tube. 1 

The equalization of air between the cavity of the tym- 
panum and the pharynx, which is constantly going on, is 
kept up by means of these muscles, especially during the 
act of swallowing, since they are inserted on the cartilagin- 
ous wall of the tube, and act on its walls by their muscu- 
lar contraction, and thus open the passage, which is other- 
wise closed. 

We have already spoken of these conditions, and I have 
referred you to the various experiments and observations 
which furnish insurmountable facts as to the influence of 
the muscles of deglutition, and of the act of swallowing 
itself, on the mechanism of the tube. It is certain that 
each normal or hindered action of these muscles, as well 
as of their antagonists, the inferior muscles of deglutition, 
has an influence upon the equalization of the air in the 
ear. We cannot conceive of a continuous, equable con- 
dition of the middle ear in all its parts, unless the muscu- 
lar action, immediately and indirectly connected with the 
act of swallowing and the mechanism of the tube, be ab- 
solutely undisturbed. 

It is even conceivable that the fibers of the various 
muscles concerned in the act of swallowing, which run so 
near to the surface of the mucous membrane, and which 
lace themselves about the glands of the soft palate, would 
be themselves affected, in a long continued and intense 
inflammation, and thus changes in structure be caused. 
Although there is a certain probability in this belief, no- 
thing can be said with absolute certainty on the subject, 
since the parts have not been examined with reference to 
this view. In regard to the occurrence of recognizable 
pathological changes of structure in the palatine muscular 

i Petro-Salpingo-Staphylinus, or Elevator Palati, and the Spheno-Salpingo-Staphylinus, or 
Tensor Palati. 



.; 



CONNECTION BETWEEN PHARYNX AND EAR. 3OI 

apparatus, as a result of chronic pharyngeal catarrh, all 
that we may yet certainly say, is, that the functions of these 
muscles are impaired by such a morbid process. Hyper- 
trophy of the glands of the palate, swelling and thickening 
of the membrane of the pharynx and Eustachian tube, are 
the most common results of catarrh, and certainly increase 
the task of the muscles in question. Such results are 
common, and are at times very formidable. Even if the 
muscles do not increase in size to any extent, as we see 
occurs in the compensatory hypertrophy of the heart, in 
valvular insufficiency — although from all the facts of the 
case we have reason to believe the contrary — a mispropor- 
tion between the power possessed and work demanded, 
will at least be developed. The muscles of the palate and 
of the Eustachian tube will not fully perform their duties, 
but will become relatively insufficient. Now then, a 
normal capability for action in this important apparatus is 
positively necessary in order to secure a healthy condition 
of the middle ear. Any insufficiency of this sort, such as 
may be caused by a chronic catarrh of the pharynx, will 
certainly, therefore, produce abnormal conditions of the 
ear. 

The great importance of the palatine muscles for the 
hearing power was first made known by Dieffenbach, who 
showed that most patients with cleft palate were also hard 
of hearing. In such cases the muscles have no fixation 
point from which to exert an influence upon the Eustachian 
tube, and consequently it, with the entire middle ear, be- 
comes affected. Semeleder, in his excellent monograph on 
rhinoscopy and its practical value, 1 first called attention to 
the fact that the mouth of the tube has an entirely different 
shape from the normal in cases of fissure of the palate. 
According to Dieffenbacb the impairment of hearing was 

1 Rhinoscopy and Laryngoscopy. Translated by Dr. Edward T. Caswell. 



302 EXAMINATION OF THE PHARYNX. 

always "completely relieved" after the closure of the pal- 
atine fissure by sutures. 

You see, gentlemen, that when we examine the matter 
more closely we find a great variety of ways by which 
affections of the naso-pharyngeal cavity may continue 
themselves on the Eustachian tube and cavity of the 
tympanum. You now, perhaps, understand better my 
abrupt giving up of the subject of aural catarrh, and will 
believe that I am correct in stating that in a certain 
and large class of affections of the ear, we are obliged to 
consider the condition of the naso-pharyngeal mucous 
membrane. 

Examination of the pharynx. — Most persons are not 
able to hold the tongue down when they open the mouth. 
We are thus compelled to use a tongue depressor. The 
best are broad and short ones, with a hinge joint, so that 
one part may be used as a handle. If you cause the pa- 
tient to take a deep inspiration, or to articulate "A," in a 
loud voice, the uvula will be elevated, and we are enabled 
to see both arches of the palate, the tonsils, and the whole 
portion of the posterior wall of the pharynx. If we then 
press down the whole of the tongue, instead of its tip 
merely, we can get a deeper view, which includes the base 
of the tonsils, and the surrounding parts, even to the 
epiglottis, whose upper portion, in some men, but es- 
pecially in children, is thus brought to light. 

We see a great many different conditions in such an 
examination, for there are a great variety of morbid 
changes which take place in these parts. Sometimes the 
mucous membrane, so far as we can see, is intensely red- 
dened, and swollen in such a manner that the isthmus 
faucium becomes extremely narrowed, and the boundaries 
and borders of the different parts are merged into each 
other. The redness may be either a bright red, or only a 



GRANULAR PHARYNGITIS. 303 

bluish red, in which latter case the parts are surrounded by 
an oedematous border. Sometimes only single parts are af- 
fected, the uvula, for instance, which hangs down as a long 
and broad sac, or the tonsils are very irregular and fissured 
in appearance, a result of many previous abscesses, or they 
project out to the center of the soft palate, and have on 
them whitish nodules or yellow pustules. In adults of 
more than thirty years great hypertrophy of the tonsils is 
not so common as a general oedema of the mucous mem- 
brane. 

Sometimes a few round elevations appear on a slightly 
reddened base. They are somewhat even and dry, re- 
sembling the gelatinous granules of trachoma, in the stage 
of diffuse inflammation, as they appear in blennorrhcea of 
the conjunctiva. These demarkated swellings vary in 
breadth and thickness exceedingly. They occur chiefly on 
the posterior wall of the pharynx. At times there are 
only a few isolated ones ; again they occur in groups, and 
then resemble granulations. On this account this form of 
pharyngeal inflammation has received the name of granular 
pharyngitis, 

B. Wagner 1 first described this affection from an anatomical stand- 
point. According to him it is an affection of the follicular tissue. 
The granulations are neo-plastic formations, or infiltrations of the 
mucous membrane. On section they are found to be of a medullary 
structure, and only apparently circumscribed. If laid for some time 
in alcohol, they acquire a white color. In more minute sections a 
large collection of little bodies resembling lymph corpuscles, is found 
in a fine reticulate connective tissue. Sometimes quite broad lym- 
phatics are seen in this fibrous net-work surrounding the follicle in a 
circular manner. 

The mucous membrane lying between has sometimes a 
, strikingly pale and flabby appearance, and .sometimes, on 

1 Archiv fur Heilkunde, VI, 1895, s. 318. 



304 EXAMINATION OF THE PHARYNX. 

the contrary, it appears dense and tense, as if shrinkage 
had occurred. Large swelling of red relaxed mucous 
membrane, symmetrically arranged on both sides of the 
pharynx, behind the palato-pharyngeal arch, are often seen. 
In other cases the mucous membrane, as far as we can fol- 
low it, appears very pale, smooth and thin, and traversed 
by thick varicose veins, while the thin, long and flabby 
uvula hangs down like a needle. 

Irregularity in the arch or curvature of the soft palate 
is Jess common in acute than in chronic affections of the 
pharynx. On the one hand, we often see the uvula 
pushed more or less obliquely to one side, without any 
paralysis of the facialis. On the other hand the position 
of the uvula is often unchanged in facial paralysis. In one 
case, that of a boy, I once found that the oblique position 
of the uvula was due to a dentated, irregular and deep 
cicatrix on the posterior aspect of the soft palate. Of 
course it could only be detected on a rhinoscopic exa- 
mination, t 

Very often the space between the two arches of the palate 
is very large, without being filled up with a tonsil, and the 
posterior arch is very near the pharyngeal wall, so that the 
entrance into the naso-pharyngeal cavity is very narrow. 
The latter named appearance seems to indicate a thicken- 
ing of the soft palate, that is, of the broad part bordering 
on the fauces. We may, at times, assure ourselves of an 
irregular hump-like arching forwards of the soft palate, by 
means of a catheter introduced through the nose, and 
moved about in this region. The instrument will show, 
by means of a peculiar doughy feel, that there is a diffuse 
swelling of the upper pharyngeal space. We may often 
draw out, with the catheter, great masses of half dry, 
green mucus, such as are sometimes visible on opening the 
mouth, lying in drops or firmly adherent and incrusted on 
the posterior pharyngeal wall. 

i 



RHINOSCOPY. 305 

Rhinoscopy* — Until recently, we have been unable to 
examine the upper pharyngeal, or naso-pharyngeal cavity, 
in which the important pharyngeal opening of the Eus- 
tachian tube lies, except in those rare instances in which 
there was a fissure of the palate, or a considerable defect 
in the structure of the nasal meatus. 

Bidder 1 was able to see the whole superior pharyngeal space, with 
the motions there taking place, as well as those of the soft palate, in 
a case where a greater part of the nose and cheek was removed for 
the purpose of extirpating a tumor. Meniere 2 saw the opening and 
shutting of the mouth of the tube in the act of swallowing, to the 
extent of about two centimetres, in the case of a patient who had a 
large perforation of the nose. 

Humanity has to thank the energy and talent of J, 
Czermak for making practical the examination of the 
larynx with small mirrors. This method was several 
times attempted, and the way prepared for its accomplish- 
ment, but it was again given up. Laryngoscopy has now 
become a generally cultivated and greatly developed part 
of the field of science. Czermak also conceived the simple 
as well as ingenious idea of turning the face of the laryn- 
geal mirror upward, and of thus examining the naso- 
pharyngeal space. This method of examination is called 
rhinoscopy. We use the same little steel or glass mirrors 
as in laryngoscopy. We generally need to fix the handle 
of the mirror at an angle slightly different from that on 
the laryngeal mirrors. We also require a tongue spatula ; 
the jointed one already mentioned is the best, the patient 
being able to hold it himself. We may also require, in 
some cases, a broad hook for lifting up the uvula. 
When there is no sunlight, which is best adapted for 

1 Neue Beobachtungen, iiber die Bewegungen des Gaumens, etc., 1858, s. 9. 
a Gazette med de Paris, 1857, No. 19. 

39 



3 o6 



RHINOSCOPY. 



the purpose of illuminating the parts, I use an Argand 
study lamp, over which is placed an illuminating lan- 
tern (Levins), by means of which the light is retained, 
and transmitted through a strong double convex lens. 
We may either allow the light to fall directly on the 
pharynx, or turn it upon it by means of Semeleder's 
illuminating spectacles. These consist of a strong spec- 
tacle frame, on which, by means of a joint, a concave lens 
is fastened. 

In spite of all these appliances, rhinoscopy is yet by 
no means an easy matter, and we are only able, after long 
practice, to see what is to be seen. The parts to be 
recognized are the posterior surface of the palate, the 
nasal openings, with the ends of the inferior and middle 
turbinated bones, the pharyngeal opening of the Eustach- 
ian tube and its vicinity, and the posterior wall of the 
pharynx. 



Fig. 29. 




TobolcCs illuminating apparatus. 



RHINOSCOPY. 307 

(For the practice of rhinoscopy, I use a simple Argand 
burner, without the condensing apparatus, in connection 
with a laryngeal mirror fastened on the forehead by means 
of a band similar to the one sketched on page 68. To- 
hold's apparatus 1 is most recommended by laryngoscopists 
of the present day, as a source of illumination. St. J. R.) 

The successful use of the rhinoscope may be much 
facilitated by the previous introduction of a polished Eus- 
tachian catheter. It is imperatively necessary, in a rhino- 
scopic examination, that the patient do not spasmodically 
contract or lift up the uvula. In order that it may be as 
relaxed as possible, even while instruments are in the 
pharynx, Czermak advises that the patient pronounce a 
nasal vowel. Lowenberg suggests that the patient breathe 
as much as possible through the nose. Any great sensi- 
tiveness of the pharynx, so that its muscles contract spas- 
modically at every touch, or a tendency to vomiting, with 
great constriction of the entrance to the throat, are 
hindrances which not only render the examination difficult, 
but sometimes prevent a thorough one, even after many 
trials. This state of things is quite often present in just 
the patients with which the aural surgeon has to deal — 
those who have chronic pharyngeal catarrh. However, as 
the surgeon becomes more skillful from practice, such cases 
become more rare. 

The upper pharyngeal space is seldom the object of any 
exact anatomical observation; its normal as well as patho- 
logical conditions, therefore, are generally not sufficiently 
studied and understood. It is a part so hidden and out 
of the way, that in ordinary post mortem sections it is 
rarely brought into view. You should prepare for your- 
selves sections of the head, or take from fresh subjects the 
two temporal bones, or its petrous portion, by means of 

1 Vide Tobold on Chronic Diseases of the Larynx. Translated by Dr. G. M. Beard. 



308 ANATOMY OF NASO-PHARYNGEAL SPACE. 

two cuts made with the saw, one passing through the mas- 
toid process, the other through the zygomatic process of 
the malar bone. You will be surprised, both by the un- 
common richness of the parts in vessels, and the succu- 
lence and thickness of a mucous membrane which many 
physicians have never seen in their whole lives, and which 
they have never considered as the point of origin of many 
of the affections of their patients. You cannot examine 
many such sections without finding some abnormal appear- 
ances in the parts. 

The most common appearance is hypertrophy of the 
glands, especially in the palatine arch, where it may be so 
great that this part is three or four times its usual thick- 
ness. You will also find swelling and hyperemia of the 
whole mucous membrane, or of individual parts. This 
hyperemia may have led to greater or smaller extravasa- 
tions, under the epithelium, or on the surface itself. 
Bloody sputa no doubt comes much more commonly from 
the upper cavity of the pharynx than is generally believed. 
The presence of fresh blood, mingled with pharyngeal 
sputa, shows how often hemorrhages occur under the mem- 
brane of the pharynx and in the glands, as do also its 
remains, the "black pigment which is so often found in the 
vicinity of the Eustachian tube. 

The blackish color of the pharyngeal sputa often arises from par- 
ticles of soot which have been accidentally lodged in the naso- 
pharyngeal space. If in the evening the study lamp burns badly, 
and the soot arises, the expectorated matters are always tinged with 
black the next morning. 

In order to convince one's self of the degree of de- 
velopment of the grape-shaped mucous glands of the wall 
of the pharynx, we have only to prepare a piece of its 
membrane, and hold it up to the window. The peculiar 
protuberant bodies (schwellkorper) on the the nasal open- 



ANATOMY OF NASO-PHARYNGEAL SPACE. 309 

ingSj and on the posterior extremity of the turbinated 
bone, are very often found to be hypertrophied also. 

In chronic pharyngeal catarrh the trumpet-shaped mouth 
of the tube is sometimes very wide, its lips standing 
unusually far apart from each other. At times we may 
press white, glairy mucus from the glands, and we 
sometimes thus expose white and brown calcareous 
concretions of various size, and frequently of a 
sac-like shape, which are firmly buried in the tissue. 
Superficial roundish losses of substance are seen oftener 
than deeper ulcerations, and are observed not only in 
syphilis and tuberculosis, but where these diseases do not 
exist. 

Folds or pockets, and bands of tissue — probably aris- 
ing from suppuration and exfoliation of the coatings of 
glands — are found in the fossa, just behind the mouth of 
the tube (Rosemuller's fossa). This is an extremely vas- 
cular and glandular depression behind the tube, at the base 
of the skull, in the median line. Just here, where, accord- 
ing to Kolliker, great masses of encysted glands are con- 
gregated, so that the structure of the tonsils repeats itself, 
and where, especially in old persons, cavities are some- 
times found filled with material similar to pus, I found 
in an ear patient who had suffered nineteen years from 
phthisis, a somewhat prominent swelling about the size of 
a cherry, which, on being incised, exhibited a pultaceous 
mass of a whitish yellow appearance. 1 In a post mortem 
section of a person thirty-five years of age, who had been 
deaf and dumb, I found at the same point a similar but 
far larger swelling filled with a thick, yellow, brownish 
mass, which consisted of mucus. Such cystoid structures 
are, perhaps, degenerated mucous glands, and are not very 
rare in the throat. At least I have often observed that a 
patient, immediately after the use of the catheter, ejected 

* Virchow's Archiv, B. 18, s. 78. 



3 I O RUSTY-COLORED PHARYNGEAL SPUTA. 

such masses of puriform or mucous secretion, so that he 
would describe it as a cc sac full of mucus," which had 
been pushed into by the catheter. 

In one case the ejection of such sputa alarmed me for a 
time not a little, because the mingling of blood and mu- 
cus in the interior, and its external appearance, causes it 
to look like pneumonic sputa. The patient — an old 
gentleman — expectorated a great deal in the afternoon and 
morning, after the Eustachian catheter was used. When 
he showed me two handkerchiefs full of the expectorated 
matter, my first thought was of pneumonia. The patient 
relieved me of my fears by breaking out in the voice of a 
Stentor: "You think there is something the matter with 
my lungs! In the year 1848 I was first president of the 
House of Commons. My chest then proved its capabili- 
ties, and to-day I went again on the tribune to cry down 
the noise." This quieted my fears. At that time we had 
the good fortune to have in Wiirzburg the first authority 
on sputa, Biermer, so I sent the patient to him, in order 
that his chest and sputa might be more thoroughly exa- 
mined. 

At first it seemed to Biermer also, that the sputa was 
pneumonic, but he found the lungs perfectly sound, and 
after a thorough examination he decided that the expec- 
torated substance which had alarmed me so much must 
have come from the nose or fauces. Probably it came 
from some kind of a cyst, or mucous gland in the pharynx, 
which emptied its contents after the use of the catheter. 
I do not know that a similar case has been previously ob- 
served. At any rate rusty-colored sputa is generally 
accepted as pathogomonic evidence of pneumonia. 

Rhinoscopy may also give us accurate information 
during life as to all the above-named and other patho- 
logical conditions in the naso-pharyngeal space. Recent 
and little cultivated as this method of examination still is, 



RHINOSCOPIC APPEARANCES. 



3" 



it has already furnished many interesting contributions to 
the pathology of the naso-pharyngeal space. SemelderV 
observation on this subject may be particularly referred to, 
as well as those by Czerrnak, Gerhardt, Turk, and Voltolini. 
The later communications of Voltolini and Lowenberg* 
should also be mentioned. 




The posterior nares as seen in rhinoscopy. (Mackenzie.) 

s «, septum nasi ; j, superior turbinated bone ; m, middle turbinated 
bone ; z, inferior turbinated bone; a, superior meatus-, b, middle meatus; 
c, inferior meatus; e, orifice of Eustachian tube; r, ridge between the 
Eustachian opening and the lower border of the nasal fossa. 

The following may be named as among the interesting 
appearances observed by the rhinoscope: 

i. Pharyngitis at the opening of the tube, and extended 
over the whole superior pharyngeal space. 

1. Unsymmetrical position of the mouths of the tube. 

3. Want of development of the lips of the tube. 

4. Long, smooth, and semi-circular swellings of the 
mucous membrane in the vicinity of the tube. 

5. Plugs of mucus, or a coating of mucus at the orifice 
of the tube. 

1 Caswell's Translation of Semeleder's Rhinoscopy and Laryngoscopy, page 45, et seq. 
a Archiv fur Ohrenheilkunde, 1, 2. 



312 RHINOSCOPIC APPEARANCES. 

6. Mucous polypi of the turbinated bones, as well as 
pharyngeal polypi. 

7. Large ulcerated surfaces in the upper pharyngeal 
space. These occur not alone in syphilis, but also when 
that disease does not exist. 

8. It is by means of rhinoscopy alone that we may be 
able to detect an adhesion of the mouth of the tube from 
cicatrization. There are several such cases described in 
the literature of the subject. One has been lately re- 
corded. It was observed after death, 1 however. 

9. Rhinoscopy also explains certain difficulties met with 
in the use of the Eustachian catheter, that are caused by 
bulging out and hypertrophy of the nasal septum, or 
by anomalies in the pharynx. 

Symptoms of pharyngeal catarrh. — The symptoms 
of chronic catarrh of the pharynx are very different in 
different cases. Often, even in the severest forms, the pa- 
tient has no idea that he has any affection of the throat. 
He will, however, just remember, on close questioning, that 
for years, especially in the morning, he has expectorated 
considerable quantities of mucus. Others speak of a cer- 
tain dryness, or an unpleasant tickling in the throat, which 
is very annoying, and demands the frequent use of cold 
fluids, or that the part be moistened with bon-bons, or 
the like, for relief. Others complain of a certain diffi- 
culty of swallowing after even the slightest cold, and of 
various kinds of severe pain during deglutition. With 
these slight complaints you will also hear of the great 
annoyance from the constant accumulation of mucus. It 
requires some considerable trouble to remove it from the 
throat, and the muscles thus frequently called into service 
may be at length forced into morbid action, and vomiting 
be produced. 

1 Lindenbaum, Archiv fur Ohrenheilkunde, I 4, s. 295. 



PHARYNGEAL CATARRH. 3 I 3 

Perhaps the morning vomiting of intemperate persons, 
who all suffer from severe pharyngeal catarrh, is to a great 
extent produced by the straining necessary to remove the 
excessive pharyngeal secretion. This unpleasant symptom 
generally occurs in the morning, just after getting up. 

As a consequence of the head being on a vertical line 
with the body during sleep, and the long inaction of the 
muscles of the throat, a considerable quantity of mucus 
is collected; this becomes dry and dense, and adheres 
quite firmly to the membrane, in little lumps. A con- 
sideration of these conditions enables us to explain the 
fact that the symptoms of catarrh of the pharynx are most 
decided in the morning, and are the more prominent the 
longer the patient has slept, the worse the air which he has 
breathed during the night, and the more he has exposed 
his pharynx on the evening before — that is, the more he 
has smoked and drank. In addition to the dryness of the 
mouth, which is occasioned in such patients by the "cold 
in the head," and by the necessity, on account of inter- 
ference with nasal respiration, of sleeping with the mouth 
open, such patients also feel a heaviness in the head, and 
fullness in the ears. These symptoms will be relieved 
when they have used a gargle and taken a glass of water or 
cup of coffee, after which the mucus is loosened and easily 
removed. At times, however, the increased ejection of 
sputa continues during the whole forenoon. A patient of 
this class, who seemed to be a person of temperate habits, 
assured me that these unpleasant symptoms disappeared 
when he held a small quantity of brandy in his throat for 
a short time, which, he said, <c cleared his wind-pipe." 
Sometimes patients eject, at greater or less intervals, bits 
of dried and hardened mucus, which are always of the same 
shape, for instance that of a small ball. 

We quite often meet with gastric symptoms, in connec- 
tion with chronic catarrh of the pharynx, which must 
40 



314 NERVES OF PHARYNX. 

result from the contact of the secretion of the pharynx 
with the mucous membrane of the stomach. The secre- 
tion of the pharynx is sometimes so excessive as to be 
almost a pharyngeal blennorhcea, and the whole of the 
mucus cannot be ejected, but is swallowed, and passes 
down into the aesophagus of itself. Although we know 
very little of the chemical constitution of the sputa of the 
pharynx, yet we may believe that the stomach will not 
tolerate it in any great quantity. 

Many observations have convinced me that many forms 
of the neuralgia which so often occurs in chronic catarrh, 
and which generally appears as a pain in the forehead and 
back of the head, are closely connected with this affection. 
In order to convince you of the possibility of such being 
the case, I have only to call to your mind the many head- 
aches which depend on affections of organs that are re- 
motely situated. Severe pain in the head is very often 
one of the symptoms of diseases of the eye, stomach, and 
kidneys, as well as of the uterus. Of course we cannot 
relieve such a pain until we reach the cause. 

Nerves of the pharynx. — The palate and pharynx a.re 
parts very richly supplied with nerves. 

The trigeminus furnishes motory as well as sensory 
fibers; the motory from the pterygo:dens internus of the 
third branch, and the sensory as well from the second as 
the third branch. The spheno-palatine ganglion also, com- 
municates with pharyngeal branches, and with the descend- 
ing palatine nerves, and the otic ganglion, with branches 
to the tensor of the soft palate. The facial nerve should 
also be mentioned, from which, according to most authors, 
a little branch goes to the uvula — the glosso-pharyngeus, 
from which, as is well known, a great part of the sensation 
as well as motion of the pharynx proceeds. The pneumo- 
gastric sends two branches to the mucous membrane and 



IMPORTANCE OF PHARYNGEAL AFFECTIONS. 315 

muscles of the pharynx. There are numerous connections 
of the accessorius Willisii (spinal accessory) with the pharyn- 
geal branches of the pneumo-gastric, and just as branches 
from the pneumo-gastric unite to form a nervous plexus 
in the pharynx, so also is a plexus pharyngeus formed 
from the sympathetic. 

Thus we see that there are few parts of the human 
organism that are so immediately connected with so many 
different nerve tracts. Is it probable that pathological 
conditions in parts so abundantly and variously innervated, 
only declare themselves by local symptoms? May we 
not rather believe that they may excite affections in other 
nerve tracts, and in other organs of the body? If pharyn- 
geal affections are studied more closely, we shall find 
more and more facts which will demonstrate their connec- 
tion with other diseases in a manner much more evident 
than I have indicated in the foregoing remarks. 

It still remains to be said, that the affections of the 
upper and lower portions of the pharynx often produce a 
bad odor from the mouth and nose. Sometimes we per- 
ceive this at a considerable distance, as soon as the patient 
breathes with his mouth open. More commonly we first 
notice it when examining a case, and the patient makes 
an expiration with his mouth open. It is also very un- 
pleasantly perceived in the use of the catheter. It has 
something of the odor of stinking cheese. Not unfre- 
quently it is not noticed by the patient, but it is unspeak- 
ably sickening and uncomfortable to the surgeon if he is 
at all sensitive to odors. An odor resembling that from 
fresh meat may also be considered as one of the unplea- 
sant exhalations occurring from pharyngeal catarrh. 

Nasal catarrh. — Chronic catarrh of the nasal mucous 
membrane is very frequently connected with the same kind 



3 l6 NASAL CATARRH. 

of an affection of the ear and pharynx. There is also a 
bad odor from the nostrils of the patient, when this affec- 
tion exists, one that recalls the odor of black currants. It 
occurs particularly in females, and is almost always increased 
during the period of menstruation, and sometimes appears 
at this time only. The patients do not seem to be 
aware of such nasal exhalations, and they generally assert 
that there is no unpleasant odor from the nose. 

In chronic nasal catarrh the secretion is not so often in- 
creased as diminished. Most of its victims suffer from 
the so-called "stoppage in the head." (Stockschaupfen.) 
The nose is very dry, they seldom need a handkerchief. 
They complain very often of an unpleasant sensation of 
thickness and stoppage in the nose. Its permeability for 
the purposes of respiration is more or less impaired by 
the swelling of the mucous membrane. 

If the secretion from the nose has been very abundant 
for a long time in an adult, we must consider the possi- 
bility of the existence of polypi. An exact examination 
will sometimes detect these where the patient, and even 
the physician, had had no suspicion of their existence. 
Nasal polypi are often overlooked if they are not so large 
that on a vigorous expiration they are forced towards the 
external nasal meatus, or when they do not completely 
stop up the affected side. It is a question whether they 
do not often take their origin from the antrum High- 
moriani. 

Luscbka and Giraldes 1 have shown that cysts and actual 
polypoid proliferations from mucous membrane, very 
often occur in this cavity. In sixty post mortem exa- 
minations, made without choice, soft polypi were found in 
the antrum, five times. Inflammatory affections of this 
cavity may be sometimes detected on the living subject. 
Such patients speak of a pain limited to the cheek bone, 

i Virchow's Archiv, B. VIII and IX. 



NASAL POLYPI. 317 

of a circumscribed sense of heaviness, and a sensitiveness 
which at times increases to a toothache. 

As is well known, the superior dental nerves run close 
beneath the covering of the antrum, so that when its mu- 
cous membrane is swollen these nerves are apt to be 
pressed upon. In such cases, masses of yellow mucus are 
often evacuated, generally in large quantity at one time, 
and I may venture the supposition that they proceed from 
the adjacent cavity. 

For the purpose of examining the nasal mucous mem- 
brane we may use an aural speculum, and illuminate the 
nasal cavity by means of the concave mirror. Kramer s 
valvular speculum is well adapted for the same pur- 
pose, the nasal passage being capable of distension. The 
halves of the speculum may be made a little flatter than in 
the one used for the ear. The anterior portion of the infe- 
rior turbinated bone is sometimes so much thickened that 
the inexperienced examiner may mistake this superficial 
thickening for a polypus. 

We have already said that this same bone sometimes ap- 
pears in rhinoscopy as a bluish red, irregular swelling pro- 
jecting into the pharyngeal orifice of the tube. 

(If the face of the patient be turned towards a window or 
other illuminated surface, we may expose the nasal cavities 
very thoroughly, in most cases, by simply pressing upon 
the nasal septum with the thumb until the alae become 
widely spread apart. St. J. R.) 






LECTURE XX. 

SIMPLE CHRONIC CATARRH (CONTINUED). 

Comparative frequency; hereditary predisposition; appearance 
of the membrana tympani; auscultation of the ear; kind 
and degree of the impairment of hearing; participation of 
the mastoid process; prognosis in accordance with the differ- 
ent varieties of chronic catarrh. 

Gentlemen: Observations on the cadaver as well as 
on the living subject, teach us that chronic aural catarrh is 
by far the most frequent of all the affections of the ear, 
and that it thus becomes the most common cause of im- 
paired hearing. 

Chronic catarrh of the ear is an affection of every time 
of life. It occurs in early childhood. It then developes 
itself more frequently from an acute or sub-acute affection, 
but it is the most common cause of the impaired hearing 
of advanced life. 

It cannot be denied that there may be an hereditary 
tendency to this disease. I know families that are gene- 
rally healthy and long-lived, in which scrofula and phthisis 
pulmonalis never occur, where, for generations, the greater 
number of the members of these families, no matter in 
what different circumstances they may live, are affected 
with chronic catarrh of the ear, in consequence of which 
not a few of them have become somewhat deaf. When 
we consider that certain family similarities, which have 



TUBAL CATARRH. 319 

been transmitted through several generations, are founded 
in some similarity in the construction of the skull, we 
may ask if the same thing may not occur with reference to 
the osseous part of the organ of hearing, so that pecu- 
liarities in its structure may be inherited, just as well as 
a particular shape of the nose. 

The amount of space in the cavity of the tympanum 
as well as the width of the bony portion of the tube, 
varies very much in different persons. It cannot be denied 
that a certain amount of malformation of the part would 
favor adhesions, frequent closure of the tube, etc. This 
question might be answered, as I believe, by anatomical 
examinations and exact measurements. Of course we 
often meet with this affection in persons with scrofula and 
tuberculosis, as well as in persons who are disposed to 
catarrhal affections of other mucous membranes. 

Catarrh of the Eustachian tube, or tubal catarrh, 
very often occurs in children and very old persons. In 
the case of the former, the fissure-like shape of the 
pharyngeal orifice, as well as the relative density of the 
pharyngeal mucous membrane, may explain the fact that 
at each cold, closure of the tube so readily takes place. In 
old persons, on the contrary, we seem to have an abnormal 
relaxation of the parts, and a want of power of the mus- 
cles of deglutition. They are consequently not able to 
draw away the membranous wall of the tube with sufficient 
regularity and force. This relaxation and want of power 
seem to occur quite frequently in anaemic and debilitated 
persons — for example, in chlorotic females, convales- 
cents, etc. The same state of things must occur in the 
case of paralysis of the tri-facial, it being connected to the 
internal pterygoid nerve, which supplies the tensor palati. 
It may also occur, perhaps, in paralysis in that part of the 
pneumo-gastive which furnishes motory nerves to the 
levator palati. How far diseases of respiration may affect 



320 CHRONIC AURAL CATARRH DIAGNOSIS. 

the functions of the tube, and thus of the ear, we cannot 
determine until the influence of the movements of respira- 
tion on the equalization of air in the ear is shown to be 
one that is absolute and constant. 

A sclerosing and thickening process very frequently 
occurs in marasmic individuals who have a dry and deli- 
cate skin, and a very irritable nervous system. Hence, 
when it takes place in the middle ear, and causes dullness 
of hearing, the affection is generally considered as nervous 
deafness. This form of impaired hearing is not frequently 
found after a severe course of hydropathic treatment, or 
after the careless employment of sea baths. 



Diagnosis. — How may we recognize chronic aural ca- 
tarrh? The appearance of the membrana tympani plays 
a prominent part in the diagnosis of this affection. Its 
position, as the elastic and transparent boundary wall of 
the cavity of the tympanum, as well as its anatomical 
structure, possessing as it does on its inner surface, a con- 
tinuation of the mucous membrane lining the middle ear, 
renders it a good stand-point for a diagnosis. The morbid 
changes that occur upon it in the sclerotic form of chronic 
aural catarrh, are the least striking. In this variety of 
disease the membrana tympani may be exceedingly bril- 
liant, and, as it were, abnormally stretched over the cavity. 
At the most it is somewhat more opaque than normal on 
the periphery, or there is a reddish yellow mingled with its 
color. This mingling of colors is most strongly marked 
in the center of the posterior half. 

In true chronic catarrh of the cavity of the tympanum, 
on the contrary, we find quite a variety of abnormal con- 
ditions on the membrana tympani. These alterations pro- 
ceed from morbid processes in the mucous layer of this 
membrane. They are frequently propagated upon the 
lamina propria, or fibrous structure, whose internal layer, 



MEMBRANA TYMPANI IN AURAL CATARRH. 32I 

or the one consisting of circular fibers, is dependent for its 
nutrition upon the layer of mucous membrane lying upon 
it. The outer surface is generally of a normal brilliancy, 
except in very old, or somewhat acute cases, where it looks 
dull, as if it had been breathed upon. The epidermis and 
the cuticular layer are then somewhat affected. The light 
spot is very often altered. It is only rarely that it is 
broader than normal. Its boundaries are often indistinct, 
while it does not extend so far towards the periphery, or 
its course is interrupted in various directions. Sometimes 
it is reduced to a small point, or to a small line. It may 
be entirely absent, or only a slight indication of its pre- 
sence may exist. All these are conditions which we must 
refer to some abnormal condition in the curvature or ten- 
sion of the membrana tympani, if there are not other 
appearances which show that the superficial layer of epider- 
mis and the cuticular layer are alone affected. 

Vessels are only seen on the membrana tympani when 
recent congestive conditions are also present. They then 
run along the handle of the malleus, or behind it, looking 
like fine red lines. The malleus is usually very distinct, 
the corium not being thickened. It appears frequently 
very prominent, and it is dragged abnormally inwards, so 
that it appears more or less shortened in the perspective, 
in which case the little nodule at its upper extremity — the 
short process of the malleus — is so much the more 
prominent. 

The membrana tympani is not infrequently very con- 
cave, and there are points where it is more drawn inwards 
than at others, as we have already mentioned in speaking 
of adhesive processes on the cavity of the tympanum. 
They vary greatly in position, extent, and shape. Most 
frequently the anterior half of the upper part of the mem- 
brane lies abnormally. The appearance of the membrana 
tympani in chronic catarrh of the cavity of the tympanum 
4i 



322 MEMBRANA TYMPANI IN AURAL CATARRH. 

may be distinguished from that of the normal condition, 
in that it is less translucent, and appears somewhat thick- 
ened. It then seems very markedly drawn inwards from 
the sharply demarkated anterior edge of the handle 
of the malleus. In other cases, in connection with 
this increased concavity of the membrana tympani, the 
handle of the malleus appears curved inward like a saber. 
The natural pearl grey appearance is changed to a dark 
grey ; the color of the membrane, in the long-continued 
course of the disease, passes through all the intermediate 
changes, from a whitish grey to a pearl white; from a 
bluish to a yellowish grey. The periphery is often thicker 
and the most intensely grey. It often even appears as a 
distinctly defined whitish ring of various width. On the 
border where the mucous membrane of the cavity of the 
tympanum is continued upon the inner surface of the mem- 
brana tympani, where, in a normal condition, the mucous 
membrane is most developed, the abnormal relaxation, or 
thickening, as a rule, is seen first, and takes place to the 
greatest extent. While in the normal membrana tympani 
the mucous layer is the thinnest of all, when a catarrhal 
process has occurred, there is often very considerable swell- 
ing and hypertrophy, so that it is thicker than the whole 
membrana tympani should be. 

Even a slight degree of relaxation and exudation may 
very greatly impair the transparency of the membrana 
tympani, and cause very great changes of color. I need 
only to remind you of what we learned as regards the 
color of the membrane, that is, that it results from a com- 
bination of colors. Thickening of the membrane acts, 
therefore, not only on the color of the drum, by changing 
its own peculiar hue, but by preventing the passage of any 
rays of light. Hence the mingling of a yellowish tint is 
prevented. This tint, in a normal membrana tympani, 



i 



MEMBRANA TYMPANI IN AURAL CATARRH. 323 

depends upon the reflection from the promontory through 
the membrane. 

We do not always, however, find the appearance of the 
membrana tympani much changed in chronic catarrh of the 
middle ear, where the cases are recent, although the cathe- 
ter and other means of diagnosis, may distinctly indicate 
the existence of a catarrh. It often only appears a little 
dull and moist, with a slight yellow color mingled with its 
normal tint. The color is thus not so even- — some points 
are less translucent. In general the appearances are not 
equable, either in color or density, but exist in different 
places to a very different extent. We often find in the 
posterior half of the membrane a spot in the form of a 
whitish grey, opaque half moon, which lies between the 
outer edge of the membrane and the handle of the mal- 
leus, so that there is a portion normally translucent in 
each direction. Wilde has likened this half moon shaped 
opacity to the arcus senilis of the cornea. It may be seen 
in young persons, however, and is by no means a constant 
appearance in old ones. 

According to Politzer, who examined several such cases 
with the microscope, these spots, looking like tendon, 
were found to be "depositions of fat corpuscles and gran- 
ular matter between the fibres of the membrana tympani." 
We find also, in the same position, other calcareous de- 
posits, beginning generally in a round-shaped spot. This 
spot may unite with the posterior half of the half moon 
shaped one, and thus form a ring in the shape of an elon- 
gated horseshoe. These calcareous deposits are easily dis- 
tinguishable from the tissues round about, by their yel- 
lowish white, or pure white color, and are not to be 
mistaken. They resemble atheromatous spots on the 
internal coat of an artery. Sometimes they involve all 
the layers of the membrana tympani, and sometimes the 
outer surface of the membrane is unchanged, so that it is 



324 CALCAREOUS DEGENERATIONS. 

continued over these spots with an unaltered and superficial 
brilliancy. These calcareous deposits are seen in early 
youth, and are by no means infrequent. 

In speaking of purulent affections we shall again allude 
to these calcareous degenerations of the membrana tym- 
pani. They very often exist, even when very large, in 
conjunction with very good hearing power, as numerous 
observations show. I have found very extensive calcare- 
ous degenerations on the membranse tympani of students 
who have been attending my lectures, who stated that their 
hearing was not at all impaired. 1 

Besides these changes, radiate striae, running from the 
<c umbo" to the periphery, are sometimes seen. Some- 
times they do not appear until after the air douche, or 
inflation of the membrana tympani, has been employed. 
There are also peculiar whitish points to be sometimes 
seen on the membrana tympani, anteriorly and above. 
They are certainly situated in the mucous layer, but I can 
give no more exact idea as to their nature. 

We have already briefly shown, in one of the preceding 
lectures, how adhesive alterations of the membrana tym- 
pani, that is, its abnormal adhesion to portions of the 
walls of the cavity of the tympanum, may exhibit them- 
selves by greater concavity of the whole membrane or by 
depressions of various parts. These conditions may be 
more distinctly seen during the administration of an air 
douche. These morbid conditions are found not only as 
a result of acute catarrh, but they may be developed in 
the course of a chronic affection of the same kind. 

Apart from the already mentioned changes in the posi- 
tion of the malleus, and also in the curvature of the 
whole membrana tympani, as well as the drawing inwards of 
the portion lying in front of the upper part of the handle 
of the malleus, the indications of abnormal adhesions are 

1 Schwartze, A. F. O., I, s. 142. Chimani loc. cit., s. 171. 



ADHESIONS OF MEMBRANA TYMPANI. 325 

found in the most different parts, and vary very much in 
appearance, so that no one description suffices for all the 
conditions. They occur very often in the posterior and 
upper part of the membrana tympani, behind which, at a 
very short distance, we find the long process of the incus, 
and the head of the stapes. Corresponding to an ab- 
normal adhesion between the membrana tympani and these 
points, we sometimes find a yellowish point in its posterior 
half, above the center, which often lies in a superficial de- 
pression. The shape of the head of the stapes, with the 
arch, which its posterior portion forms with the process of 
the incus, may then be at times very distinctly seen from 
without. A yellowish line behind the handle of the mal- 
leus, and running parallel to it, shows that the long process 
of the malleus is pressed towards the membrana tympani, 
or even united to it. A fine whitish line extending back- 
wards from the short process of the malleus, is also some- 
times seen posteriorly and above, which seems to indicate 
an adhesion of the posterior pocket. This so-called pos- 
terior pocket is a cavity on the inner surface membrana 
tympani, formed by a reduplication of the membrane. It 
may be also an indication of an abnormal approximation 
of the chorda tympani, which runs along the free margin of 
this pocket. Both these conditions are not unfrequently 
met with on the dead subject, and they are often described. 

Tubal catarrh. — True catarrh of the tube is indicated 
by a peculiar condition of the membrana tympani, which 
may be generally described as a change in position or curva- 
ture of the membrane. After a closure of the tube that has 
existed for some time, we find its center, especially, very 
much depressed. It is abnormally concave, and looks as 
if sunken inward, or more properly, as if pressed inward. 
This increased concavity of the membrane is most dis- 
tinctly seen in the appearance of the handle of the mal- 



326 TUBAI, CATARRH. 

leus. This seems much shorter in the perspective. The 
short process appears more prominently above it, and with 
it the contiguous uppermost portions of the drum, which 
are demarkated from the other parts of the membrane by- 
more or less decided folds or edges. Corresponding to 
this pressing inwards of the membrana tympani, the dis- 
tance between it, and the parts of the cavity of the tym- 
panum lying behind it, is lessened. Thus we often see 
the promontory through the membrana tympani, especially 
the edge above the niche for the fenestra rotunda. 

We are most frequently able to distinguish the vertical 
process of the incus behind the membrana tympani, upon 
which it really lies. The triangular light spot is often 
broader, but at the same time shorter, than normal, and 
very indistinct. Not unfrequently above or behind the 
shore process of the malleus we see a diffused reflection. 
The color and thickness of the membrane may be at the 
same time completely unchanged. It often appears thin- 
ner, as if atrophied. Wilde calls this condition "collapsed 
membrana tympani!* Sinking inwards of the membrane is, 
however, less often a result of primary weakness — an inde- 
pendent atrophy of the fibrous portion of the membrana 
tympani — than it is a consequence of long-continued, une- 
qual atmospheric pressure, that is, pressure exerted on the 
outer surface of the membrane only, by which, in the 
course of time, its equable condition has been altered, and 
which, as it seems to me, has caused a thinning and 
atrophy of its fibrous structure. We may often see how 
much the membrana tympani has changed in its position 
of equilibrium, by causing the Valsalvian experiment to 
be practiced, or by blowing in air through the catheter. 
The drum then moves very much outward, but immedi- 
ately falls back into its former position. 

If a general thickening of the membrana tympani has 
resulted from an affection of the cavity of the tympanum, 



TUBAL CATARRH. 327 

occurring at an earlier period, or simultaneously, of course 
all these indications of the closure of the tube are less 
distinct. On the other hand, the appearances are much 
more marked when only certain parts of the membrane are 
thickened. If, for example, a circumscribed thickening of 
the periphery of the membrane has occurred, the center 
and periphery are markedly distinguished from each other, 
both in color and curvature. A broad zone of thickened 
tissue, and of whitish grey appearance, will remain in the 
normal plane, while the transparent, greyish red center 
sinks inwards, like a funnel. This line of depression 
marking off the center from the periphery, is generally 
most distinctly seen on the anterior and lower part of the 
drum. We often see, on the angle or edge thus formed, a 
characteristic brilliant line, in the region of the triangular 
spot of light. (Politzer.) 

Thus much, gentlemen, as regards the exceedingly vary- 
ing appearances of the membrana tympani, which you 
may find in the objective examination of patients. Allow 
me now a few words as to the value of these in individual 
cases, so that you may not expect too much from one means 
of diagnosis. Although an exact examination of the mem- 
brana tympani is imperatively necessary for the proper 
estimation of a case of disease of the ear, and although it 
is one of the most important standpoints for observation 
as to the condition of the middle and external ear, you 
must not think that the appearance of this membrane 
alone, is sufficient for the determination of the nature of a 
morbid process in the organ of hearing, and for the ex- 
planation of the existing impairments of function. 

On the one hand, I need only to call to your mind how 
many of the previously mentioned abnormities of the 
membrana tympani we have found in some of our fellow 
students, who not only believe that they hear well, but 



328 DIAGNOSTIC VALUE OF MEMBRANA TYMPANI. 

who actually show themselves capable of fulfilling all the 
demands made upon their hearing power by the practice 
of auscultation. Catarrhal affections of the middle ear 
occur so very frequently, especially in infancy and child- 
hood, that it is not surprising that a great many of them 
run their course without any marked impairment of the 
hearing, although certain changes on the membrana tym- 
pani may remain. 

Politzer has shown that some opacities of the membrana tym- 
pani may be referred to congenital anomalies of development. 

You will easily understand, furthermore, that the medi- 
um which transmits the vibration from the outer to the 
middle ear, is much less important for the final perception 
of sounds by the auditory nerve, than that which conducts 
the sound from the middle to the inner ear. As long as 
the latter, that is, the fenestra? of the labyrinth, and 
especially the structures about the fenestra of the vesti- 
bule — the stapes and its membrane — are perfectly normal, 
the membrana tympani may be greatly altered, without 
any marked impairment of the hearing. 

We can never decide as to the degree of the impairment 
of function from the appearance of the membrana tym- 
pani alone. 

In medico-legal cases — for example, in the case of the examina- 
tion of conscripts — where we cannot admit the testimony of the 
person being examined, it is especially important to remember the 
proper value to be given to the appearance of the membrana tym- 
pani, in deciding as to the hearing power. 

The mucous layer of the membrana tympani is gene- 
rally in the same condition with that which lines the cavity 
of the tympanum. The normal or morbid conditions in 
the latter are generally continued upon the former, although ! 



DIAGNOSIS OF CHRONIC AURAL CATARRH. 329 

there are exceptions to this rule. According to numer- 
ous pathological investigations, catarrhal processes occur 
in the cavity of the tympanum which may localize them- 
selves on individual parts, for example, on the fenestras 
ovalis and rotunda, without there being any affection 
whatever of the mucous membrane of the membrana tym- 
pani. There may, therefore, be no morbid alteration of the 
membrana tympani in a decided case of catarrhal deafness. 
This is, however, an exceptional case. The membrana 
tympani, as a rule, furnishes us with very valuable conclu- 
sions as to the condition of the middle ear, and as to the 
kind and nature of the morbid processes located in that 
part. 

The statement of the patient as to the history of the 
case, the influences that affect his hearing, making it bet- 
ter or worse, are also valuable assistances in the diagnosis 
of chronic aural catarrh, although not always. So, also, 
are the examination of the pharyngeal space and the use 
of the Eustachian catheter. 

We have already spoken of the course and subjective 
symptoms of chronic aural catarrh, as well as of the mor- 
bid processes in the pharynx. We have also learned the 
various results of auscultation on blowing air through 
the catheter, but we must refer to this subject once more. 
I£ we wish to give an exact opinion as to the condition of 
\ the mucous membrane of the tube, we can scarcely dis- 
I pense with the use of the catheter, and the practice of 
j auscultating the ear. We thus learn whether the tube 
I is swelled, if it is of normal width, or contracted, that is, 
if the resistance from its walls to the stream of air, be 
normal or increased, and if there be any abnormal amount 
of mucus in the tube or in the cavity of the tympanum. 

It is certainly conceivable that some adhesive processes which act 
very materially by lessening the space in the cavity of the tym- 

42 



330 DIAGNOSIS OF CHRONIC AURAL CATARRH. 

parvim, but of which the appearance of the membrana tympani gives 
no clue, may exert an influence on the sounds heard on auscultation, 
and that thus we may obtain an idea of their presence. 

Among the different sounds that are heard, sometimes, certain pe- 
culiar short and heavy, as well as some vibratory sounds occur, which 
we know arise from the middle ear, because of their seeming nearness to 
the ear of the examiner, and which are essentially different from the 
" striking sound," depending on the striking of the air upon the 
membrana tympani. I can only, indefinitely indicate the sub-varieties, 
and have therefore not mentioned them before. We shall only 
obtain decided conclusions as to their nature by a post mortem exa- 
mination of persons upon whom such sounds have been heard ; or 
possibly by auscultatory experiments on a cadaver, which is at the 
same time anatomically examined. 



Some abnormal conditions of the membrana tympani, 
for example, the radiate striae, are often not seen until 
after the air douche has been employed. An examination 
during the air bath also informs us as to the elasticity, 
mobility or abnormal fixation of the membrane. We 
have no other certain means of learning these latter-named 
conditions. 

Thus, we must consider catheterization of the Eustachian 
tube as very important in the diagnosis of chronic catarrh, 
but we must, on the other hand, guard ourselves against 
the error of overestimating it, and from forming conclu- 
sions not justified on strict criticism, or on an anatomical 
basis. If the stream of air enters fully and freely into 
the cavity of the tympanum, without any rustling sound, 
it proves nothing more than that at the moment of exa- 
mination there is no abnormal swelling, and no morbid 
secretion of the mucous membrane. It is by no means 
proven that such conditions did not formerly exist, and 
that in the present case the impairment of hearing does 
not depend upon frequent and long continuing closure of 
the Eustachian tube, or upon changes in the mucous 



DIAGNOSIS OF CHRONIC AURAL CATARRH. 33 I 

membrane of the cavity of the tympanum, in other words, 
upon a catarrhal process. 

In many cases the appearance of the membrana tym- 
pani, the statements of the patient, in short, all the other 
symptoms, indicate that there is a chronic catarrh of the 
middle ear, with a thickening process of the mucous 
membrane, or that the tube has been closed for a long 
time, and yet the air passes through the tube without any 
sort of hinderance, without any increased resistance, and 
without any sound indicating increased secretion. We can 
estimate this resistance by the amount of pressure required 
on the air bag. We very frequently find in decided cases 
of chronic catarrh, particularly those that have existed for 
a long time, that the stream of air enters with an uncom- 
monly full and loud tone. This is most strikingly seen if 
the patient has been for some time deaf in one ear, in con- 
sequence of catarrh, and the same affection has more 
recently occurred on the other ear. While the air strikes 
freely and fully upon one drum, in the other, more re- 
cently affected, and the one with better hearing power, it 
meets with considerable resistance, and enters in a fine 
whistling stream, or only during the act of swallowing. 

After a long continuing inflammation a certain dryness 
of the surface, and a shrinkage of the connective tissue 
basis occurs, just as we may see, after severe trachoma, 
when an abnormal dryness of the conjunctive, and a per- 
fect absence of secretion result. (Xerophth almost) This 
condition, which may be observed on the living subject, 
may be frequently found in an examination of the cadaver. 

I have several times called your attention, in the patho- 
logical specimens which I have presented to you, to the 
marked width of the upper portion of the Eustachian 
tube. It occurs in cases where a severe suppurative 
inflammation in the cavity of the tympanum had existed 
for some time. Here we might conceive of a distention 



332 DIAGNOSIS OF CHRONIC AURAL CATARRH. 

of the walls by a collection of secretion, or of a disturb- 
ance in the nutrition connected with subsequent atrophy 
of the bones. Such a widening also occurs in old cases 
of catarrh of the ear which have left behind morbid 
changes in the cavity of the tympanum. 1 

An aural catarrh may also occur which localizes itself 
chiefly in the cavity of the tympanum, and causes little or 
no alteration in the tube. In very many cases every 
anomalous symptom in the tube, or in the sounds heard 
in auscultating the ear, may be absent, and yet the im- 
pairment of hearing be caused by a pathological condition 
of the cavity of the tympanum, which possibly itself pro- 
ceeded from a primary affection of the tube. 

If I have spent too much time in discussing this point, 
it has been because the most of practitioners only con- 
sider themselves justified in making the diagnosis of "ca- 
tarrh of the ear" when moist rattling sounds occur on the 
use of the catheter, or if the permeability of the tube is 
removed or impaired. The name "tubal catarrh," which 
is so limited in its signification, is also frequently used by 
physicians to designate catarrh of the middle ear. 

Of course too slight a consideration of the changes in 
the cavity of the tympanum goes hand in hand with an 
overestimated value of the signification of the results of 
auscultation, which can furnish conclusions as to the con- 
dition of the mucous membrane at the time of examina- 
tion only. 

This want of recognition of the condition of things is 
not confined to the aurists of a former period, and gene- 
ral practitioners of the present day, but it is most clearly 
expressed in the writings of some modern aural surgeons. 
You will see that in this way a great number of cases of 
catarrh, especially those where the morbid process is 
interstitial, are overlooked, or referred to other causes 

i Virchow's Archiv, B. XVI, sec. 10, n ; ibid., B. XXI, p. 299. 



DIAGNOSIS OF CHRONIC AURAL CATARRH. 333 

than the true one. We shall have occasion at another 
time to notice that these cases have been classed together 
under the head of "nervous deafness," and that thus the 
nervous affections of the ear have taken too large a place 
in the diagnosis of aural disease. 

Catheterization, or, to speak in more general terms, the 
administration of an air douche to the ear, furnishes valu- 
ble assistance in the diagnosis of individual cases, in other 
respects than those mentioned. If the patient hears bet- 
ter immediately after its use, if the tinnitus aurium is 
markedly diminished by the air bath, we are able to say 
that these impairments of function depend upon morbid 
conditions which may be influenced in a purely mechanical 
way. They thus allow of at least a relatively favorable 
prognosis. The subsequent examination of the mem- 
brana tympani, and further general observation, will de- 
termine the "degree and duration of the improvement. 
The case can then be more exactly analyzed, since these 
mechanical effects may be produced in various conditions 
of the parts, such as closure of the tube, excessive secre- 
tion in the Eustachian tube or cavity of the tympanum, 
abnormal adhesions, and so on. 

The kind and degree of the impairment of hearing may 
also indicate to some extent the parts that are especially 
affected. The more frequently do sudden changes occur 
in the hearing, the more is the Eustachian tube involved. 
Every Eustachian tube is more permeable in dry weather, 
and does not open so readily when there is much moisture 
in the air. All mucous membranes to which the air is 
accessible, become heavier and thicker from receiving 
water from the atmosphere. In moist weather there is 
also an increased secretion of mucus in the tube, which 
causes its walls to be more firmly united, so that there is 
more muscular action required to draw them apart. 

A slight swelling of the mucous membrane, that in a 



334 DIAGNOSIS OF CHRONIC AURAL CATARRH. 

person with healthy ears would cause no unpleasant symp- 
toms, will have a bad effect upon the ear in a person whose 
Eustachian tube has at all times a small caliber, on account 
of chronic hypertrophy of the mucous membrane and the 
glandular layer, and which only opens on an energetic 
swallowing action, or upon a person whose impairment of 
hearing is made more noticeable by any, however slight, 
diminution of the hearing power. Hence, such patients 
always do well to restore the communication of air between 
the pharynx and middle ear several times a day, by clos- 
ing the mouth and nose, and then forcing in the air. 
Wilde calls this procedure "inflation of the membrana 
tympani." 

When, however, the impairment of hearing is not 
affected in this way, the predominant cause is probably in 
the cavity of the tympanum. When the impairment of 
hearing is very great, we are obliged to believe that 
changes have occurred on the most important parts (acous- 
tically), that is, on the two fenestrae leading into the 
labyrinth. I must call your attention, however, at this 
point, to a great gap in our knowledge. We have no 
means, as yet, of determining, on the living subject, the 
particular seat of the morbid changes, that is, any more 
exactly than has been just indicated. 

Politzer says, on this point: "We have no way of de- 
termining whether a given impairment of function depends 
on an adhesion of the head of the malleus to the upper 
wall of the cavity of the tympanum, for example, or upon a 
diminished mobility of the stapes in the fenestra ovalis." * 
Perhaps an examination with the tuning fork, of which I 
have already spoken in detail, may lead to some distinc- 
tive conclusions on this point. 



In the observations thus far made on the subject of 

i Archiv fur Ohrenheilkundes, I I, s. 60. 






MASTOID PROCESS IN AURAL CATARRH. 335 

chronic catarrh of the ear, one part of the organ has been 
left completely unnoticed. This is the mastoid process. 
Let us now see what may be said of the participation of 
this section of the ear in the affection just named. 

The number and extent of the air cells of the mastoid 
process, or, in general terms, their development, density, 
and porosity are so various that in persons of the same 
age great differences are observed. With our present 
knowledge we are not always in a condition, in a given 
case, to say if a certain appearance in the mastoid process 
should be characterized as morbid or physiological. You 
can see how difficult it is, under these circumstances, to 
obtain positive conclusions as to the pathological changes 
on the mastoid process, even on the cadaver, and how 
carefully we must proceed. In some cases of thickening 
of the mucous membrane of the cavity of the tympanum 
of one ear, I found that the mastoid process of the same 
side had very small cells, being quite solid in structure, 
while on the other side the air cells were very large. It 
can not certainly be decided if such difference in cell de- 
velopment may not occur without the existence of chronic 
catarrh. However, there is a very great probability, when 
the middle ear has been for a long time in a condition of 
congestion and hyperemia, that the space containing air 
gradually begins to enlarge by means of increased secretive 
power, and that through increased formation of bone a 
hyperostotic tendency may also occur, such as is often 
seen in all parts of the body, and which ends in chronic 
inflammation of the periosteum. A fact that goes to 
show that the mastoid process often participates in the 
chronic inflammations of the ear, is the one that many 
patients complain of frequent pain in this part, and when 
there is an exacerbation of the catarrh, they have a sensation 
of hearing or fullness behind the ear. How far such an 
increase in density of the mastoid process affects the other 



336 MASTOID PROCESS IN CHRONIC CATARRH. 

parts, and how much it injures the hearing, we do not 
know, since no observations have been made as to the 
greater or lesser capability of the mastoid cells for contain- 
ing air during life. It is probable that we may obtain 
some light by auscultation of the ear, and percussion of 
the bone, and by ascertaining the degree of hearing power, 
by placing the watch over the mastoid process, as com- 
pared with other results. It is, however, as yet, advisable 
to simply consider all these observations without being in 
haste to draw conclusions from them. 

Let us turn to the consideration of the physiological 
importance of the mastoid process, in order to deter- 
mine what results must obtain from the described al- 
tered condition of the air-containing property of these 
cells. It is a generally accepted opinion that the pur- 
pose of these air cells, this porous structure, is to give 
this firm support of the soft parts a certain lightness. 
But there must be some further purpose than this. The 
air cells of the mastoid process increase the quantity of 
air in the ear, which is set in motion by means of the 
acoustic vibrations. They are — with every circumscribed 
fixed body, and every circumscribed quantity of air in the 
vicinity of the labyrinth — to be compared to a resonator, 
or sounding board. We cannot say how far any diminu- 
tion in size of these parts may place the hearing below 
the normal standard. 

This hollow space in the vicinity of the cavity of the 
tympanum has also a greater importance, in that it is a 
sort of air reservoir, by means of which all sudden 
changes in the cavity of the tympanum, such as often 
occur as to the quantity of the air, may be equalized, and 
thus rendered less effective. We have noticed several 
times, previously, how, in simple swallowing with the 
mouth and nose closed, that the air was considerably 
rarefied, and the membrana tympani pressed inwards, as 



DIAGNOSIS OF CHRONIC AURAL CATARRH. 337 

we may determine by an examination, or by Politzer's 
aural manometer. This same state of things occurs also 
in a strong respiratory action, for instance, in sneezing, 
spasmodic coughing, or violent blowing of the nose. We 
also know that a strong condensation of the air in the 
middle ear, with pushing out of the membrana tympani, 
may be noticed when air is pressed from the lungs into 
the ear by the Valsalvian experiment, or by the catheter, 
or Politzer's method. 

Again, such a sudden increase in the pressure of the air 
occurs in the cavity of the tympanum, but the membrana 
tympani is pushed inward from a very loud report, such as 
that of a cannon, or the blast of a trumpet, beating of a 
drum, etc., near the ear. A great effect will be produced from 
such a change in the pressure of the air upon the small 
quantity of air in the cavity of the tympanum, and in the 
upper parts of the tube, and how easily must a solution of 
continuity occur in one part or the other of the middle ear. 
Either a laceration of the membrana tympani, of the mem- 
brane of the fenestra rotunda, a pushing of the stapes into 
the vestibule, or a separation of the extremely delicate 
articulation between the incus and stapes, or other injury 
may occur, according to the force and direction of the 
powerful movement of the air. All these accidents will be 
less likely to happen when the pressure of the air is more 
equally divided by having access to the various spaces. 

Thus, sclerosis of the mastoid process is to be reckoned 
among those conditions which favor the occurrence of 
those severe symptoms depending upon increase of the 
intra-auricular pressure, that we have already described in 
our remarks on closure of the tube, and its consequences. 

Prognosis. — The prognosis of chronic aural catarrh is 
in general terms a favorable one. We are able to act di- 
rectly upon the seat of the affection with the help of the 
43 






338 PROGNOSIS OF CHRONIC AURAL CATARRH. 

catheter, that is, upon the mucous membrane of the mid- 
dle ear, in the most various manner. Yet in this general 
statement two exceptions must be made. On the one 
hand there is no sufficient radical treatment for a catarrhal 
process of any mucous membrane, while, in our climate, 
the causes are constantly acting, and are almost unavoida- 
ble. (This is also true of the northern part of the United 
States.) On the other, in persons who have at one time 
suffered from aural catarrh, a locus minoris resistenti<e, a 
point of lesser resistance, is formed, and thus every cold, 
every slight cause of disease, has an effect on the ear. 

I know a patient who is annoyed by an increased tin- 
nitus aurium y or dullness of hearing, immediately on put- 
ting on a shoe or boot that has been for some time in a 
cold room. There are some persons, therefore, who need 
a continuous treatment, merely to get rid of the residue 
of repeated affections. 

The prognosis is also unfavorable because the subjective 
symptoms are so few, the course of the disease so insidious, 
and the impairment of hearing appears so slowly and so 
unnoticed^ that the greater number of the patients observe 
it first after some degree of deafness has existed for a 
long time — it may be for a term of years. But you 
may ask, how much or how little can we do for a case of 
old and deeply-rooted catarrh? The state of the case 
here, gentlemen, is about the same as that in old catarrhal 
affections of other organs. We can do about as much 
for the old catarrhal affections of the ear as for those of 
any other part of the body. The conditions are especially, 
unfavorable for a cure of chronic catarrh of the ear, on 
account of the peculiar structure and contracted space of 
the cavitv of the tympanum, and Eustachian tube. The; 
morbid changes in this part which must inevitably cause a 
catarrhal process of long duration, may very easily favor 
the progress of the affection, and increase the influence of 



PROGNOSIS OF CHRONIC AURAL CATARRH. 339 

an injurious impression which may be of itself an affair of 
slight moment. 

I need only to recall to your mind the effect of adhe- 
sions or thickening of the mucous membrane of the mid- 
dle ear, as we have described them in speaking of acute 
catarrh. If, therefore, the pathological state has advanced 
to a certain degree, it contains in itself all the require- 
ments for an increase in the morbid condition, both in an 
anatomical and functional respect. 

It is well, therefore, in such cases, not to have too great 
expectations in our own minds, or to cause them to be 
raised in those of our patients, as to what art can do, but 
we should be contented if we are able to stop the disease 
in its progress, and permanently retain the hearing power 
that may exist. Without direct local treatment the affec- 
tion must finally lead to complete deafness. 

We may possibly esteem such an amount of surgical 
assistance too lightly. It is something, however, to pre- 
serve a person — who has been growing deaf from ten to 
twenty years, and who in ten years more must be dead to 
the ordinary intercourse of life — from the entire loss of 
his hearing power. 

Compare, if you please, what may be done here, with 
that which is accomplished in severe inflammations of the 
other mucous tracts, although they have for years rejoiced 
in scientific treatment, and although, in the latter class of 
affections, the patients, as a rule, call for the assistance of 
a physician at a very early period. Do we have any very 
sanguine hopes of a patient who has suffered for years 
from decided catarrh of the lungs or bladder? Do you 
not consider yourselves fortunate when you maintain the 
status in quo in such cases? There are cases enough where, 
i in spite of the greatest care and the most favorable circum- 
stances for treatment, we are not able to prevent a further 
advance of the disease. The older the patient, the longer 



34° PROGNOSIS OF CHRONIC AURAL CATARRH. 

the catarrh has existed, and the more changes that have 
already taken place in the cavity of the tympanum, the 
less, of course, are we able to improve the condition of 
things. Yet, in some cases which promise very little at 
the outset, we may be able to accomplish considerable by 
a long-continued local treatment. 

The prognosis of aural catrrrh is not among the worst 
as compared with that of other diseases, because in by far 
the greater number of cases, if the condition of the pa- 
tient be not too unfavorable, we may check the progress 
of the affection, and obviate the evil influences of relapses. 
In recent cases, and those that are not very old, we may 
very often improve the condition very much. 

The prognosis will be a much more favorable one when, 
as time goes on, the recent instead of the old cases become 
the subject of medical treatment. You must do your 
part, gentlemen, in order that this state of things may be 
improved. In addition to the fact of the slightness of 
the subjective symptoms that are generally produced by 
chronic aural catarrh, there is a deficiency in the number 
of physicians who are willing to treat an ear case, both of 
which circumstances cause patients to allow an affection 
of the organ of hearing to advance to a great extent before 
assistance is sought. When the laity once know that 
affections of the ear in their incipiency, are recovered from, 
at least as rapidly as other affections, but that when they 
have existed for some time they are as little amenable to 
treatment as other diseases, and when there are physicians 
enough who know how to examine an incipient aural affec- 
tion, and how to use the Eustachian catheter in its treat- 
ment, the prognosis of catarrh of the ear will be quite 
different from that which it now is. 

In classifying the prognosis of the various forms of this 
disease, I would say, that according to my experience 
those classes are by far the most unfavorable where the 






PROGNOSIS OF CHRONIC AURAL CATARRH. 341 

changes in the membrana tympani are diffuse, and it ap- 
pears thicker throughout all its layers, without any con- 
siderable change in its color or surface. 

In such cases, where we seem to have a kind of sclerosis 
of the mucous membrane of the cavity of the tympanum 
that has been going on for years, we will be fortunate if 
we succeed so far as to diminish the tinnitus aurium. 
Such cases do not generally come under medical observa- 
tion until loss of elasticity on the fenestrae of the laby- 
rinth, or perhaps secondary changes in the labyrinth have 
occurred. We are then not infrequently unable to check 
the process, or preserve the patient from complete 
deafness. 

On the other hand, the prognosis in true catarrh of the 
Eustachian tube is, on the whole, favorable, if it be not 
very old, and if no secondary changes have occurred on 
the fenestrae, and in the labyrinth. By opening the tube, 
whether it be by the catheter, or Politzer's method, the 
condition is momentarily improved, and we are able, by a 
proper treatment of the pharyngeal affection, and regular 
opening of the tube, to obtain a very satisfactory and even 
good condition of the ear. Of course occasional relapses 
will occur, but their evil consequences may be prevented 
by an early local treatment. 

The prognosis is much more uncertain in true catarrh 
of the cavity of the tympanum. 

It is very unpleasant, both for patients and physician, 
that we are not able to indicate in advance, with any sort 
of certainty, those cases which have a relatively favorable, 
and those that have an absolutely unfavorable prognosis. 

We shall see subsequently how much the testing of the conduc- 
tion of sound through the bones, as tested by the watch and tuning 
fork, may avail in a diagnostic and prognostic way. 



342 PROGNOSIS OF CHRONIC AURAL CATARRH. 

The words of Schwartze 1 on this point are: Cl There 
remains nothing but the test by treatment. If a local 
treatment, persisted in carefully and rationally for a period 
of from eight to fourteen days, has no effect, either upon 
the hearing or the unpleasant sensations of the patient, 
any further treatment will probably be of no avail." I 
remember some cases, however, where treatment did not 
lead to any result until it had been persisted in for some 
time. I also remember cases where no improvement re- 
sulted until after long-continued local treatment, especially 
when the patient had used Politzer's apparatus for some 
time at home. 

Politzer ascribes an especial significance to the existence 
of tinnitus aurium in making a prognosis. "Continuous 
subjective sounds in the ear render the prognosis unfavor- 
able, and if in a case of chronic catarrh of the cavity of 
the tympanum, with constant tinnitus, a decided improve- 
ment of the hearing suddenly occurs, without any change 
in the subjective noise being made by the treatment, we 
may with great probability believe that the result of the 
treatment will not be permanent, but that sooner or later 
a relapse, or lessening of the hearing distance, will occur. 
Not less unfavorable is the prognosis in those cases when 
the affection of the ear begins with a slight tinnitus, but 
which gradually and slowly increases with time, until it is 
only till years after, that the loss of hearing has become so 
great that conversation near at hand is heard with diffi- 
culty. Here, also, treatment will cause very little or no 
improvement in the hearing." 

If the appearance of the membrana tympani indicates 
partial and circumscribed morbid changes, especially of an 
adhesive nature, if it is of a whitish color, the result of 
treatment v is often more favorable than the other con- 

i Prakt. Beitrage zur Ohrenheilkunde, 1804, s. 24. Wiener Mediz Zeitung, 1865, 
Nos. 67-72. 



PROGNOSIS OF CHRONIC AURAL CATARRH. 343 

ditions, that is, the age and general condition of the 
patient, duration and degree of the affection would indicate 
at the first glance. 

When large synechia? exist, however, which cause an 
entire, or nearly entire, obliteration of the cavity of the 
tympanum, I have scarcely ever seen any considerable 
improvement. 

I have several times attempted, in such cases, to draw the air from 
the auditory canal, that is, to rarefy it by means of a bit of india 
rubber tubing placed air tight in the meatus. I have also combined 
this with a pressure from within, by sending in a gentle current of 
air at the same time through the Eustachian tube. There was con- 
siderable effect, but it was not permanent. In the East a much 
esteemed popular remedy for deafness is said to be the following : A 
reed is placed air tight in the ear, and sucked upon until the blood 
flows out in a full stream. 

Cases where the deafness is very great, if there are large 
spots of calcareous degeneration in the membrana tym- 
pani at the same time, are, as a rule, very unfavorable tor 
treatment. These degenerations are generally connected 
with morbid processes on the fenestra rotunda, or ovalis. 

An impairment of hearing which has not existed very 
long, even if of a high degree, and one that is still becom- 
ing worse, always promise a much better result from treat- 
ment than those cases of impaired hearing that began 
years ago, and especially those that have remained at about 
the same point for years. 

In the former class of cases we should always exercise 
due caution in speaking of the amount of improvement 
that may be expected from treatment. As yet we are not 
able to say with certainty to what extent, and of what 
character are the changes that may have occurred on the 
most important, and, unfortunately, most inaccessible 
parts of the cavity of the tympanum, for instance, on the 



344 CASE OF RUPTURE OF ADHESIONS. 

two fenestra, nor are we able to determine how mnch part 
the contents of the labyrinth have taken in the morbid 
process. 

(The following case, although not strictly belonging to the subject 
which has been discussed in the preceding pages, is inserted as proba- 
bly being one of rupture of synechia? in the cavity of the tympanum, 
from the shock of an explosion near the ear. It was communicated 
to me by Dr. y. C. Hildreth^ of Chicago, lately in charge of the 
Desmarres (U. S. army) Eye and Ear Hospital : 

General states that in i860 he was affected for the first 

time with a "gathering" in both ears. His friends thought that 
there was some dullness of hearing. The patient, however, was not 
aware of it. Attacks of suppuration occurred several times during 
the year. After that no inconvenience was felt until the afternoon 
of July 6, 1862, while with the United States army at Harrison's 
Landing, Virginia. The patient had been greatly fatigued by an ex- 
tremely arduous and anxious campaign, during the latter eight days of 
which he had little sleep or food. On the afternoon in question he 
became suddenly sick and dizzy, so much so that he was obliged to 
dismount from his horse. The attack passed off, when he re- 
mounted, but was again obliged to dismount and go to his quarters, 
where he suffered from severe headache, and afterward became 
unconscious for about thirty minutes. When consciousness returned 
the patient found that he was deaf, and that his right arm and leg 
were partially paralyzed. 

While unconscious, sixteen grains of sulphate of quinine were 
administered. This was repeated the next morning, and blisters 
were applied back of the ears. Patient recovered to some extent, 
and July 19 returned to his home in Pennsylvania. August 1, a 
surgeon inflated the Eustachian tubes, applied blisters behind the ears, 
followed by caustic issues. The patient also took mercury until sali- 
vation was produced, followed by iodide of potassium. October 1, 
he began to hear loud sounds in the left ear only. Paralysis of arm 
and leg greatly diminished. November 29, 1862, he reported to 
Dr. Hildreth for examination. His condition was found to be as 
follows : Eustachian tube pervious ; both membranae tympani were 
very concave and brilliant ; triangular light spots prominent ; drum 
moved during the Valsalvian experiment ; both ears were very sensi- 



CASE OF RUPTURE OF ADHESIONS. 345 

tive ; patient could hear the sound of loud speaking near the ear, but 
he could distinguish nothing clearly ; he could hear the whistle of a 
locomotive, and the noise of the cars when riding in a train ; by the 
aid of a speaking trumpet he could carry on a conversation ; his 
general health is improving, although he is still feeble. Dr. Hil- 
dreth's diagnosis was anchylosis of the stapes, with sub-acute inflamma- 
tion of the cavities of the tympanum. 

The patient returned home, and June ist, 1863, resumed treat- 
ment. He took a preparation of iodine for six weeks. Counter 
irritation was kept up on mastoid process by means of nitric acid. 
Eleven days after, a purulent discharge occurred from each ear, which 
lasted four weeks in the right ear, but several months in the left. 

Patient improved a very little until February, 1863, not being yet 
able to hear conversation without the tube, when he was engaged in 
shooting at a target with a musket. The gun of a comrade was 
loaded with nearly a double cartridge. Patient was obliged to fire 
the gun himself or expose the intended trick. The shock of the 
explosion was very great. Simultaneous with the report of the gun, 
loud crackling sounds were heard in the ears. There was also a 
great deal of pain experienced. The patient slept soundly for four 
or five hours after taking an anodyne. On awaking the General 
found that he could hear without the tube, with close attention to the 
speaker. The general health and hearing continued to improve. 
There was some nausea after the concussion just described, as well 
as dizziness. 

The patient was again examined by Dr. Hildreth in March, 1863. 
He could then hear a watch eleven inches from the right auricle, 
and nine from the left. There was a slight purulent discharge from 
the right auditory canal. The patient believes that the discharge 
from the ear, in i860, was due to boils in the meatus. He con- 
tinued in service until 1865, when he was mustered out, the war 
having ended. 

In December, 1867, the patient wrote to a patient of the editor as 
follows : " My hearing is not dull enough to cause any inconveni- 
ence, except when the ears are obstructed by boils." 

The above case seems to be one of rupture of adhesions in the 
cavity of the tympanum, from the concussion described. The sud- 
den improvement to the hearing can hardly be attributed to any other 
cause. St. J. R.) 

44 



LECTURE XXI. 

TREATMENT OF CHRONIC CATARRH OF THE EAR. 

Local treatment of the ear; air bath or douche; vapors and 
gases; mechanical methods of dilatation; agents acting upon 
the outer surface of the membrana tympani; carbonic acid, 
compressed air, etc.; treatment of the mucous membrane of 
the pharynx; cauterization ; gargling, and its mechanical 
importance ; pharyngeal and nasal douche; posterior nares 
syringe; excision of the tonsils and uvula; consideration of 
the patient's general condition. 

Gentlemen: Since we have studied the nature of 
aural catarrh in all its variations, we may close the subject 
to-day with some remarks on the treatment of the disease! 
This should consist in a correction of the altered con- 
dition of the mucous membrane of the ear, nose and 
pharynx, and in an attention to the general health of the 
patient. In most cases it is not sufficient to attend to one 
of these points, but they must all be regarded. 

The strictly local treatment consists chiefly in the fre- 
quent use of the air bath or douche. By this means the 
tube again becomes permeable; any difference of the 
pressure of air in the cavity of the tympanum, or pharyn- 
geal space, is equalized, and at the same time a mechanical 
pressure is exerted upon the elastic walls of the cavity of 
the tympanum, that is, upon the membrana tympani and 
membranes of the fenestras. This pressure stretches and j 

i 



CHRONIC AURAL CATARRH TREATMENT. 347 

relaxes these parts, counteracts any incipient rigidity and 
want of elasticity, and besides it may loosen abnormal 
adhesions. 

For the purpose of giving the air bath we may use the 
Eustachian catheter, into which air is forced, either with 
the mouth or an india-rubber air bag (see cut, p. 208), or, 
in case of necessity, by means of a compression pump. 
In slight cases, and where simple closure of the tube 
exists, Politzer's method alone may be employed. When 
the tube has once been opened, it is advisable to recom- 
mend the patient to keep it permeable by the regular em- 
ployment of the Valsalvian experiment. 

(I have grown very cautious in recommending the 
employment of the Valsalvian experiment, since I have 
seen that several persons who have been in the habit of 
employing it for years, have thereby induced such a relaxed 
condition of the membrana tympani that it will not remain 
pressed out for more than a minute or two. It has been 
employed in these cases without the use of the catheter or 
Politzer's method, and when they come to be employed at 
a subsequent period, no effect is produced upon the patient. 
This is especially the case in the use of the latter named 
means of inflating the drum. St. J. R.) 

This purely mechanical effect of the air douche is not 
unfrequently sufficient of itself, in recent cases, especially 
those occurring in children, and in pure tubal catarrh. Its 
employment is also necessary in the beginning of the 
treatment of all cases, in order to make a free passage to 
the ear. 

In all cases that are not very recent, or which are not 
very slight affections, the abnormally secreting, swollen, 
or already thickened mucous membrane of the tube, or of 
the cavity of the tympanum, must also be acted upon. 
This is achieved by means of the injection of vapors or 
medicated fluids through the catheter. 



34-8 INJECTION OF VAPORS. 

The use of vapors or gases. — As long as there is a 
rattling sound in the use of the air bath, and we may be- 
lieve that there is an increase of secretion, and a moist 
swelling of the whole mucous tract, the vapor of the 
muriate of ammonia is of particular value, just as its 
inhalation is now successfully practiced in laryngeal and 
bronchial catarrh. 

Formerly I heated the powdered muriate, and blew the 
white vapor of the sublimated salt into the ear. The 
vapor is less irritating, however, and acts more favorably 
if blown in while in the process of being generated. For 
this purpose we need an apparatus consisting of three 
glass bottles connected with each other by tubes. One of 
these flasks is filled with liquor ammonia caustici, the other 
with hydro-chloric acid. They empty, by means of a glass 
tube, into the third, containing some hydrochloric acid 
mixed with water. If, now, air is blown with the mouth 
or the rubber bag, into the two first named fluids, by 
means of a double tube joined posteriorly, ammonia and 
hydrochloric acid vapor are developed, which unite, under 
water in the third flask, to ammonia, rapidly fill this, and 
may be driven into the catheter through a glass tube open- 
ing under water, to which an india-rubber tube is attached. 
(See cut on page 228.) 

The amount of pain from this procedure (or of un- 
pleasant sensation, it is scarcely a pain. St. J. R.) is very 
different in different cases. Some patients complain only 
of an unpleasant sensation of heat, others of a biting 
sensation. Others, again, complain of severe pain, but 
which is only of very short duration, partly in the ear and 
partly in the throat. 

If the patient says he only feels the vapor in his throat, 
we need not always conclude that it has not passed into 
the ear. The otoscope (or diagnostic tube), and the sub- 
sequent examinations of the membrana tympani, when 






INJECTION OF VAPORS. 349 

the vessels on the handle of the malleus are generally found 
to be injected, after the application of the chloride of ammo- 
nium, tell, generally, a plainer and more correct story than 
the patient. Generally speaking, I use the vapor daily for 
some time, consuming several minutes at each application. 
It is well to blow in simple air occasionally during the sit- 
tings. By doing this we make the tube pervious more 
quickly, and more accessible to the vapor. We cannot lay 
down any rule as to how long each sitting may require to be 
in all cases, or whether each ear is to be acted upon daily, 
or oftener. All this will depend upon the effect of the 
vapor. Generally the secretion is soon checked, the im- 
permeability of the tube is removed, and a fuller and 
stronger stream of air passes into the ear. In older cases 
the ammonia serves only as a preparatory remedy, by 
means of which a further treatment is rendered possible. 
Moist warmth is the most powerful softening agent and 
aid to resorption. On this account the vapor of warm 
water has long been used in treating thickening of the 
mucous membrane of the middle ear. We choose a high 
or low temperature for the vapor, according to circum- 
stances. I generally use from 35° to 45 Reaumer (Fah- 
renheit, no° to 133 ). The warmer it is applied, the 
oftener we must allow pauses during the application, in 
order that the silver of the catheter may not be over- 
heated, and thus cause an unpleasant burning sensation in 
the nose. The heat of the catheter is felt mostly at the 
nasal entrance, and I take care, in cases where I must use 
a high degree of heat, say 50 to 6o° R., or where the 
patient is peculiarly sensitive, to guard the part by means 
of a piece of gutta *percha, which is drawn around the 
beak of the catheter before its introduction. The effect 
of the warmth is very much less marked in the pharyngeal 
entrance to the tube, and in the cavity of the tympanum 
itself. The duration of a sitting, during which the vapor 



35° INJECTION OF VAPORS. 

is forced in, sometimes in an interrupted, again a continu- 
ous stream, varies from five to ten minutes, or longer. 

I have made various experiments in chronic cases, with 
different kinds of vapors, and when I, perhaps, except 
iodine and acetic ether, I must choose vapor of water as 
the best. Among the preparations which I have used, are, 
besides the different varieties of ether, chloroform, acetic 
acid, aceton (one of the products of the dry distillation of 
wood), acidum pyrolignosum, ol. terebinth, both alone and 
in combination with the narcotic extracts, such as extract of 
hyoscyamus, which is said to be of particular value in sub- 
duing tinnitus, and all without any especial benefit. 

We should not cease, however, to attempt to find new 
remedies, some one or other of which may be of great use 
in a particular case. The effects of remedies on a mucous 
membrane can only be made known through a series of 
observations and experiments. I should mention the 
vapor of carbonate of ammonia, of course without any 
addition of water, as another of the remedies which I have 
used. It is more irritating than the muriate of ammonia. 
This is also true of calomel and camphor, which has an 
almost indifferent effect. I have also used carbonic acid 
gas; we may use this mixed with atmospheric air, or with 
vapor of warm water. 

Ruete first advised the use of carbonic acid gas. I pre- 
pare this gas in a narrow necked flask, from broken bits 
of stone found in this vicinity, and dilute hydrochloric 
acid. The stopper of the flask has three holes, one con- 
taining a long glass funnel for the gradual addition of the 
acid, and the other two containing two glass tubes, bent 
almost at a right angle, which are connected to the pump 
and the catheter in the manner before described The 
use of chalk instead of the stones, causes too sudden and 
violent generation of the gas. On the whole, it seems to 
me a very weak, and consequently inefficacious irritant. 



INJECTION OF FLUIDS. 35 I 

Besides, the use of such a vapor for a long time may have 
an injurious effect upon the lungs. 

Of course all these applications must be made with a 
certain vis a tergo, that is, a compression pump, or the 
like, must be used if we would be certain that the air 
passes not only into the lower part of the tube, but also 
into the cavity of the tympanum itself. It is always ad- 
visable to occasionally introduce a diagnostic tube during 
the use of the catheter, in order to assure ourselves that 
the instrument has not been displaced. This precaution 
is doubly necessary when we cannot fully rely on the in- 
telligence of the patient who is holding the catheter. The 
vapor will much more certainly reach the upper part of 
the middle ear if we force it in at intervals, and not in an 
uninterrupted current. 

The injection of fluids through the catheter. — This is 
much simpler than the use of vapors, since all the appa- 
ratus that is necessary is a small glass tube (pipette), for 
obtaining the required amount of fluid from the bottle in 
which it may be contained, and for its subsequent blowing 
into the catheter. 

If the patient be made to swallow while a powerful cur- 
rent of air is driven through the catheter by means of the 
india-rubber bag, and the instrument be in the correct posi- 
tion, although the tube need not fully enclose its beak, a 
portion of the fluid in the catheter will be driven into the 
cavity of the tympanum, even if more than that which 
enters this space, runs into the pharynx or the mastoid 
process. 

Among the substances which may thus be injected into 
the middle ear, I may especially mention, as of particular 
value, solutions of sulphate of zinc (one to ten grains to 
the ounce of distilled water), chloride of ammonium (ten 
to forty grains), liquor potassae (four to forty drops), iodide 



352 INJECTION OF FLUIDS. 

of potassium (ten to sixty grains), iodine in a solution of 
iodide of potassium (one to six grains to a scruple of 
iodide of potassium). These quantities are each to be 
added to an ounce of water, like the one first mentioned. 
Glycerine may also be used in a pure state, or mixed with 
an equal amount of water, or added to any one of the 
above-named solutions. 

I have also made experiments with solutions of alum, 
carbonate of soda, dilute acetic, and hydrochloric acid. 
The latter is sometimes very efficacious, since it generally 
increases the secretion of the mucous membrane of the 
tube in a very marked manner. 

The effect of all these agents, if used in a concentrated 
form, when we except glycerine, which tends to make the 
parts more pliable, is an irritating one. The vascularity 
is temporarily increased, and thus, possibly relaxation is 
induced, or an absorbent process may be set up in the 
hypertrophied and thickened mucous tissue. In weak 
solutions alum and zinc are of course only astringents. 
There is also a disintegrating chemical effect to be ascribed 
to the ammonia and the acids. 

Experience has shown that the same benefits may be 
obtained by the injection of irritating fluids, as with the 
use of the vapor of water. Both of these means of medi- 
cation act in about the same manner upon a mucous mem- 
brane affected with chronic catarrh. There is a considera- 
ble advantage in the use of the injections over that of the 
steam, with or without the addition of irritating sub- 
stances, especially in cases where the tube is naturally nar- 
row, and consequently less of the vapor enters the cavity of 
the tympanum, because the vapor of itself moistens and 
swells the tube. The injections are also more useful if 
the vapors have an unpleasant effect upon the mucous 
membrane of the nose and pharynx, these parts always 
being in contact with the gases employed. 



INJECTION OF FLUIDS. 353 

In the use of the vapor of muriate of ammonia, we 
often have very good results from this very contact, while 
the vapor of water, especially that with the addition of 
iodine, very often makes the condition of the mucous 
membrane of the pharynx worse. We should also not 
overlook the fact that not an inconsiderable portion of 
the vapor is breathed into the lungs. 

If we now look at the dark side of the use of the in- 
jection of fluids, we find the following disadvantages: 
The beak of the catheter must rest between the lips of the 
tube, and not merely in front of its orifice, and also be in the 
same direction with the course of the tube, or all the fluid 
will run into the throat. We must, therefore, use cathe- 
ters having a large curvature. Their employment requires 
more skill than the ordinary ones. Besides, we require a 
certain assistance of the patient. If he does not swallow 
at the same time that the fluid is driven in, we may often 
fail in injecting the cavity of the tympanum. 

But in the most favorable cases a portion of the fluid 
must run into the pharynx, because the stream issuing 
from the catheter divides up, or is larger than the caliber 
of the isthmus of the tube, so that only the central por- 
tion can pass through, while the other part must flow 
downward. It is but seldom that all the fluid passed into 
the ear and none at all into the throat. In individual cases 
we can decide by auscultating the ear at the same time 
that the injection is made, whether a portion of the fluid 
actually entered the middle ear. The patient is generally, 
also, able to judge correctly as to this point. 

Subsequent examination of the membrana tympani, 
after the use of the more irritating materials generally 
shows more or less redness of its surface, just as is seen 
after the use of irritating vapors, or Politzer's air bag. 

We cannot decide in advance, just how many drops will 
enter the cavity of the tympanum. When the stream 

45 



354 INJECTION OF FLUIDS. 

driven in is a very vigorous one, some drops may pass 
through the cavity of the tympanum into the cells of the 
mastoid process. They lie at the same hight with the 
entrance of the tube, and just opposite to it. In some 
cases a further unpleasant result may be, that all the fluid 
which enters may run off the smooth walls of the cavity, 
and finally collect on the floor, and thus produce too strong 
an effect on some parts. 

It will be found best to use only a few drops at each 
injection, repeating the operation several times. If the 
patient does not succeed in swallowing exactly at the de- 
sired moment, he may take a little water in the mouth in 
order to facilitate this action. At the moment of inject- 
ing the fluid, the beak of the catheter should be pushed 
somewhat forward in the direction of the tube. 

Not unfrequently very good results are achieved by a 
combination of the two methods. After a use of the 
warm vapor of water, an injection of an irritating fluid 
may be employed. In this way the mucous membrane is 
first moistened and relaxed, and thus the fluid more 
readily and thoroughly taken up. Even in cases where 
there is no contrary indication to the long-continued use 
of moist warmth, it is well to interrupt the treatment for 
days at a time, and in the interim employ the simple air 
douche, the vapor of muriate ammonia, or astringent injec- 
tions. The injections should be only rarely employed 
once a day. Every two to three days will be usually 
found sufficient. 

(A very convenient method of using the injection is 
to place the fluid which we wish to inject in the beak 
of the catheter, by means of a small Anel's syringe or 
the like, and then stop up the outer end with a tightly fit- 
ting cork. The catheter may then be introduced without 
spilling any of the fluid, and its more certain entrance 
into the cavity of the tympanum will be favored. St. J. R.) 



INJECTION OF FLUIDS. 355 

You will sometimes observe, after a long-continued use 
of steam, to which an irritating substance, such as the 
tincture of iodine, has been added, or after irritating in- 
jections, that considerable relaxation and vascular injection 
have been produced on the mucous membrane, so that the 
patient at first hears worse, and his head seems to be full 
and heavy, while the tube is not so permeable, and he 
complains that the tinnitus has been increased. 

Some of the substances before named, if used in strong 
solutions, very frequently excite severe pain. It is very 
seldom that such pain lasts, at the greatest, more than a 
few hours. I would prefer that such symptoms of hyper- 
emia and swelling in the ear appear, than that the vigor- 
ous medication should have no effect upon it at all. It 
is always well to cause the patient to force the air into his 
ears several times during the day, either by means of the 
Valsalvian experiment, or by Politzer's method, and at 
each application of the vapor or injections we should assure 
ourselves of the permeability of the tube by means of the 
simple air douche. 

Acting upon a repeated experience, that patients with 
chronic catarrh have attained very marked results from 
treatment, where they had been accidentally affected with 
a*n acute inflammation of the middle ear, I have endea- 
vored in several cases to artificially excite an acute catarrh. 
I used for this purpose very irritating vapor, such as pure 
tincture of iodine, or concentrated acetic acid, which I 
forced into the cavity of the tympanum in a strong cur- 
rent. The pain and other symptoms occurring from this 
treatment, were generally severe, but I have never obtained 
a result proportionate to such a severe procedure, or even 
any kind of improvement in the hearing power. 

If we look at the changes that the post mortem sec- 
tion shows in patients with chronic catarrh, we may be 
able to estimate the results to be reasonably expected from 



356 OPERATIONS IN AURAL SURGERY. 

treatment. If, for example, the whole canal leading to the 
membrana fenestra rotunda is unfortunately rilled with a 
plug of connective tissue, as has often been found and de- 
scribed, or the membrane itself is very much thickened, 
inelastic, and rigid, or changed to a thin, calcareous plate, 
or if the stapes be enveloped in a rigid mass of connective 
tissue, and its base firmly united (anclylosed) to the sur- 
rounding bony tissue, I would ask if we may expect any 
result from any treatment but one that is purely operative. 

I am firmly convinced that in the practice of aural 
surgery there will yet be a wider 'field for operative inter- 
ference. The present position of the science is, however, 
not sufficiently advanced to justify experiments in such a 
direction. Every step forward must be made with great 
care, and operations should only be performed after 
repeated experiments upon the dead body and upon 
animals. 

There is no department of our art where there is so 
much practice that is simply ridiculous, as in aural medi- 
cine and surgery. Nowhere is such unscientific shuffling 
allowed and honored, as that which is sometimes seen here. 
Nowhere do we meet such a want of confidence on the 
part of both the laity and physicians as to what medical 
skill can do. He, then, who is in earnest with this matter 
of treating diseases of the ear, must avoid every appear- 
ance of the evil which has gathered about this part of our 
profession, and which has brought it into disrepute. Even 
in that most advanced of all special departments, opthal- 
mology, many operations are unsuccessful, even when 
performed by the most eminent of the profession, with 
the most correct indications, and with great skill in execu- 
tion. In the worst cases the patienf loses his eye; from 
an operation in the deeper parts of the ear, on the con- 
trary, something of much more value, the life, is put in 
jeopardy. 



DILATATION OF EUSTACHIAN TUBE. 357 

(It has been lately proposed to remove the incus from 
the chain of bones, in obstinate and severe cases of 
chronic catarrh (sclerosis), with great tinnitus aurium. 
The operation has been performed several times, but the 
results, except that no permanent harm has resulted, are 
not known to the editor. The malleus is also removed 
by Dr. Wreden of St. Petersburg. 1 St. J. R.) 

Mechanical dilatation of the Eustachian tube. — In 

cases where, in spite of the frequent use of the air douche, 
of the vapor of the muriate of ammonia, and astringent 
injections, the stream of air enters the ear in a feeble 
manner, or only with the assistance of the act of swallow- 
ing, in other words, in cases where the great narrowing of 
the tube does not depend upon hyperaemic swelling of the 
mucous membrane, but on an organized hypertrophy of 
the connective tissue, and we are dealing with a sort of 
cicatritial stricture, there remains nothing to be done but 
to enter the tube by means of bougies, and thus to gradu- 
ally enlarge the canal. I generally use cat-gut bougies for 
this purpose, more rarely probes of whalebone. Schwartze 
recommends bougies made of laminaria digit at a ; Guye, of 
Amsterdam, those made of parchment. 

All these bougies should have a blunt, conical ex- 
tremity. The length of the catheter through which 
they are to be introduced, should be inscribed upon them, 
as well as the length of the cartilaginous portion, 24 mm., 
and of the osseous, 11 mm. It is well to use a catheter 
with a large curve, and to press it very much on the nasal 
septum, in order that the beak may pass as far as possible 
between the lips of the pharyngeal orifice. 

As soon as the prpbe reaches the middle of the tube, 
the patient speaks of a painful sensation in the ear. When 
it reaches the last third, the point of transition of the 

1 Monatsschrift fur Ohrenheilkunde, Vol. 1, No. 17. 



35§ DILATATION OF EUSTACHIAN TUBE. 

cartilaginous into the osseous tube, where the canal is the 
narrowest, the local pain increases very considerably, and 
is often referred to the upper and lower teeth. One pa- 
tient always complained of a pain in the back part of his 
head. 

If the probe will not pass any further on, we may some- 
times succeed in causing it to advance by drawing it back 
a little, or by turning it on its axis. It is interesting to 
notice the very distinct movement of the bougie when the 
patient swallows. Sometimes it may be seen through the 
membrana tympani, a little above the center of the anterior 
half. 

In the most cases the appearance of the bougie on 
withdrawal, corresponds to the peculiar spiral course of 
the tube. Not infrequently, even when the introduction 
is performed with exceeding care, the bougie is found 
somewhat tinged with blood. 

The maximal diameter of the narrowest portion of the 
tube, the isthmus tubce, in adults is from iJ«,to 2 m. The 
largest bougies to be used cannot, therefore, be thicker 
than this. Where, on account of an abnormal width of 
the tube, thicker probes may be passed, there is no indi- 
cation for their employment. Probes of whalebone may 
be made gradually thicker after the first inch, which will 
greatly increase their power of resistance. In cases where 
the obstruction in the tube was very great, I have been 
enabled to make a passage with such a probe, when I had 
failed with a cat-gut one of a less or the same thickness. 
The latter are, of course, more flexible and yielding, but 
bend more on this account. 

We should begin with the smallest sizes, and pass on 
gradually to larger ones. I have observed emphysema of 
the neck, as have others, several times, after the use of 
the probes. 

In order to avoid this we cause the patient to force air 



DILATATION OF EUSTACHIAN TUBE. 359 

into his ears just before and after the probing. Some 
pain in swallowing is apt to remain for a few hours. Af- 
ter a few probings the current of air, as well as the probes, 
pass through much more freely. 

Rau recommends the use of cat-gut bougies saturated 
with a solution of nitrate of silver, in order to unite dila- 
tation with cauterization. I have seen in some cases, after 
the introduction of bougies thus prepared, excessive pain 
in the ear, with perforation of the membrana tympani. 
This may occur, however, after the use of the simple cat- 
gut bougies, and when they have been introduced with no 
great difficulty. 

On the whole, these attempts to mechanically dilate the 
tube are not very frequently necessary, although there are 
cases which cannot be satisfactorily treated without them. 
Very recently this method of treatment has been abused, 
and probes have been used with a frequency that can not 
be at all justified. 

Agents acting upon the external auditory canal and 
the outer surface of the membrana tympani. — I have 
never found these useful in cases of chronic catarrh, when 
used alone. I have never seen any benefit from the use 
of a stream of carbonic acid gas, which is allowed to pass 
into the ear, and which is so frequently advised at the 
mineral springs in Germany. It even being doubtful to 
me if the gas can pass freely through a thickened mem- 
brana tympani, if a moderate amount of pressure be 
exerted. 

Compressed air, or the pneumatic cabinet. — This is 
a means of treatment which has been lately introduced for 
the treatment of all sorts of diseases, and especially for 
"catarrhal deafness." 



360 COMPRESSED AIR NITRATE OF SILVER. 

I have seen numerous patients who have been treated 
by this apparatus, and I have never seen any permanent 
result from it which might not be attained in a much more 
certain and exact way, by rendering the Eustachian tube 
pervious. I may therefore coincide with the views of 
Magnus* who, at the close of his article on "the condi- 
tion of the ear in compressed air," says: "For this 
means of treatment where slight degrees of pressure are 
employed, much simpler means may be substituted, viz., the 
Valsalvian experiment, Politzer' s method of inflating the 
ear, and the catheter. In the employment of greater 
pressure there is considerable danger that cannot be over- 
estimated. 

Toynbee very warmly recommends pencilling the audi- 
tory canal and the membrana tympani with a weak solution 
of nitrate of silver. I considered it my duty to employ 
this method of treatment, but I have never seen any 
result from its use except that the pencilled parts became 
black. Iodine in solution, or in the form of an oint- 
ment, may be rubbed behind the ear as an adjunct in the 
treatment. 

Very recently Politzer has recommended for cases where, 
in consequence of the great inclination of the extremity 
of the handle of the malleus inwards, we may conclude 
that there has been a shortening of the tendon of the ten- 
sor tympani, that the external auditory canal be hermeti- ' 
cally closed for twenty-four hours by a plug of cloth 
saturated with fat. This remedy is used not only for the 
improvement of the hearing, but also for the diminution 
of the tinnitus. Politzer believes that in this way, he 
diminishes the effect of the external atmospheric pressure 
upon the drum, and causes a resorption and thinning of 
the air between the membrana tympani and the plug. He 
has shown by experiment that the air in the external audi- 

1 Archiv fur Ohrenheilkunde, I 4, s. 283. 



COUNTER IRRITATION. 36 1 

tory canal is rarefied by the hermetical closure of the 
passage. 

Counter irritation. — The benefits from blisters behind 
the ear, which have been until lately almost universally 
recommended in chronic affections of the organ, are quite 
doubtful. Certainly, unless combined with local treat- 
ment, they do no good whatever. 

(If they are to be used at all in chronic catarrh, they 
should be employed for a great length of time, say from 
six weeks to two months. I have had the opportunity of 
watching many chronic cases where an irritation of the 
mastoid process has been kept up for months, and never 
have I seen any other result than that a great annoyance 
was caused the patient. In sub-acute cases I believe blis- 
ters to be an efficient adjunct. St. J. R.) 

Application of remedial agents to the pharynx. — We 

may now, gentlemen, go on to consider that which 
must never be neglected— the treatment of the mucous 
membrane of the pharynx. Even in cases where no im- 
provement is to be expected, we may by this means most 
frequently prevent the further progress of the affection. 
Nothing will do so much to maintain a chronic hyperemia 
of the mucous membrane of the ear, as an old congested 
condition of the same membrane of the pharynx left to 
itself. 

Cauterization. — Cauterizations of the affected mem- 
brane do excellently well. The solid stick is better 
adapted for granulations, or where there is very intense 
general swelling. But even in the latter mentioned cases 
we should not cauterize too large a space at once, lest 
there be trouble in swallowing, and the effect on the larynx 
and trachea be too great. We should content ourselves 

46 



362 CAUTERIZATIONS OF PHARYNX. 

with touching one or two spots, especially on the side of 
the pharynx, where the red swellings already described ex- 
tend downward from the Eustachian tubes. In order to 
be able to touch the upper part of the pharynx with the 
caustic, I use a caustic holder, such as is used in cauter- 
izing strictures of the uretha, being a tube at the end of a 
strong silver wire, opening laterally. This is introduced 
through an Eustachian catheter. It is especially useful for 
circumscribed swellings, such as are often seen near the 
entrance of the Eustachian tube. 

I wouldfgenerally, however, advise you to use solutions 
of nitrate of silver, of a strength of from twenty to fifty, 
and even sixty grains to the ounce of water. For the 
lower portion of the pharynx, that opening into the 
mouth, a camel's hair pencil is best adapted for conveying 
the solution; and, for other parts, a whalebone with a piece 
of sponge attached, bending the bone according to the 
part we wish to touch, and thus we are able, while the pa- 
tient takes a long breath, not only to reach the part near 
the tube, but also even to the base of the skull, if we are 
careful. 

The irritation of such a cauterization of the upper part 
of the pharynx is very different in different cases. The 
pain caused is seldom of very long duration, and is most 
marked in swallowing. A considerable mucous secretion 
very often results, or an increased flow of saliva; some- 
times severe fits of sneezing occur, very rarely nasal 
hemorrhage. For a little time small quantities of blood 
are mingled with the expectorated matter. In a case 
where the sponge had been directed very much towards the 
mouth of the tube, a marked increase in the impairment 
of hearing was noticed for some hours after, caused by an 
increased congestive swelling of the mucous membrane. 
It is seldom necessary to use a gargle of cold water after 
such a cauterization. 



CAUTERIZATION GARGLES. 363 

The change in the pharyngeal membrane after cauteriza- 
tion, occurs very rapidly, sometimes after one or two 
applications. It is to be performed daily, or at longer 
intervals, according to circumstances. Recently I have 
been in the habit of pencilling the naso-pharyngeal space 
with a fine, long camel's hair brush dipped in a solution of 
nitrate of silver, and introduced through the nose. I can 
very warmly recommend this method in those cases where 
the tissue on the turbinated bones, and in the vicinity of 
the mouths of the tubes, is greatly swelled. I sometimes, 
though not often, pencil the pharynx with iodine and gly- 
cerine, and liq. ferri sesquichlorati, pure or diluted, or 
apply pulverized alum to isolated parts. 

Gargles. — Gargling is of great benefit to the membrane. 
The gargles may be made of cold water or mixtures may be 
used. I make them more commonly frgm alum or iodine. 

R. 

Alum pulv. 31. — £ij. 
Aq. destillat. ^viij. 
Spts. vin. gall. £i. — ^iij. 

M. 

The addition of brandy covers the astringent, un- 
pleasant taste of the alum, while common honey and 
sugar mixtures are only unpleasanter for many patients. 

Gargles of iodine are peculiarly adapted for children, 
and for cases where there is a severe swelling of the glan- 
dular portions of the mucous membrane. 

R. 

Tr. iod. Bi. 

Potass, iodid. Bij. ad ^ii. 
Spts. vin. gall. Su — 3iij. 
Aq. destillat. ^viij. 

M. 

These iodine gargles have more than a local effect on 
the parts. I have seen goitre considerably decreased in 



364 EFFECT OF GARGLES. 

size by their use, and ladies have called my attention to a 
growing smaller of the form, a slight decrease in size of 
the breasts from the same cause. 

In cases. where secondary syphilis manifests itself in the 
form of ulcers on the soft palate, on the tonsils, and on 
the edge of the tongue, in the form of pustules, or ulcer- 
ations, the tincture of iodine gargle, and also one of hydrag. 
bichlorid. gr. i-iij. ad aqua 3viij., will be found beneficial. 
Besides these, there are a variety of preparations which 
may be used with advantage. 

According to my view, gargles, in connection with the 
immediate effect of their component parts upon the struc- 
tures with which they come in contact, have another and 
perhaps essential effect, apart from the act of gargling itself. 

It is interesting to know that Celsus recommended gargles in affec- 
tions of the ear. It is not certain that he knew of the existence of 
the tube, although it r?ad been distinctly described before his time. 

If we examine the structure of the mucous membrane 
we will not only be convinced that the layer richest in 
mucous glands lies over the muscular fibers. This 
shows that these glands must be greatly affected by each 
muscular contraction, and that in many places, especially 
in the soft palate, the arrangement of the muscular fiber 
is such that it passes around, envelopes, and grasps many 
of the glands. Every energetic contraction of the muscle, 
then, must make a certain pressure on the glands, and a 
vigorous swallowing motion will assist greatly in ejecting 
their contents; the mouths of the glands being quite patu- 
lous, especially on the uvula, and anterior surface of the 
soft palate. 

Gargles, in order to do any good, must be used pro- 
perly. As generally employed, the patient standing with 
the head thrown backward, and moving the gargle about, 
with the well known roaring sound, no parts beyond the 



EFFECT OF GARGLES. 365 

teeth, the dorsum of the tongue, with the uvula, and the 
most prominent portions of the tonsils, are touched by the 
gargle. The whole muscular action consists of a strong to 
and fro motion of the uvula. In such a kind of gargling 
there can be no such thmg as contact with the posterior 
pharyngeal wall, or an energetic muscular contraction. 

Gargling must be practiced in a different manner in 
order to accomplish this latter object. Let the patient 
sit, or, better, lie down, with the head thrown back as 
far as possible, and, taking the gargle in the mouth, 
continue to make repeated swallowing motions, without, 
however, admitting the fluid into the oesophagus. Try 
this method of gargling, with simple water, in your own 
persons, and you will convince yourselves, by the sensation 
experienced, that many more parts are brought in contact 
than by the noisy method, commonly practiced; and you 
will find, furthermore, that a greater or less amount of 
mucus is ejected, during or immediately after the act, if 
the mucous membrane be in a congested condition. 

Frequent gargling, if only with cold water, is an excel- 
lent remedy in chronic pharyngeal catarrh. Not only is 
every abnormal collection of secretion prevented, and the 
normal excretion favored, but a gymnastic exercise of the 
muscles involved in the swallowing act, also occurs. 
Every striated muscle increases in volume and power, by 
means of constant and methodical exercise, as you all may 
see in gymnasiums, the exercises of the turners, etc. 

Now but apply this result of our general experience to 
the muscles of the throat, and you will see the value of 
such exercises, especially if you consider at the same time 
the importance of these muscles for the functions of the 
Eustachian tube, and for a normal condition of the middle 
ear. You remember that in chronic pharyngeal catarrh a 
great power is required of the muscles of the tube, a 
power which can only be obtained when they have been 



366 EFFECT OF GARGLES. 

developed in size and strength. You will see, if you 
recall these facts, that gargles and frequent action of 
the muscles used in swallowing, are the best remedies for 
insufficiency of the muscles of the tube, which, as we have 
seen, occurs very often in aural and pharyngeal catarrh. 

You observe, gentlemen, that I especially esteem 
gargles from a mechanical, or, if you please, a gymnastic 
point of view. I assure you these are no theoretical and 
a -priori speculations, but I have seen important results 
from simple gargling with cold water, when continued for 
a long time. 

I have seen patients who have suffered from noises in 
the ear, and difficulty in swallowing, from long-continued 
pharyngeal and aural catarrh, who, with the slightest cold, 
have pain in the throat, and increased secretion in the 
fauces, and thus add to their loss of hearing, who awake 
every morning with a burning, dry larynx, heavy head, 
and a fullness in the ear, and who remove the collected 
mucus only with much difficulty, freed, to a great degree, 
from all these symptoms, and become in every way better 
by the use of gargles, while the affection of the ear, which 
was steadily increasing, has also been brought to a stand- 
still. 

Gargling should be done at least twice a day — early in 
the morning, and just before going to bed. In many 
cases of chronic inflammations of the lower pharyngeal 
space, the patient may also use a nebulizing apparatus. 
Such patients may also snuff water, or a medicated solu- 
tion, into the nostrils every day. 

The secretion in the upper pharyngeal space is so con- 
siderable in many persons, especially around and behind 
the mouth of the Eustachian tube, that with almost every 
introduction of the catheter a mass of greenish grey mu- 
cus will be drawn out, and a loud rattling sound excited 
at the beginning of the passage of air. In such cases I 



INJECTING THE NOSTRILS. 367 

have seen important results from repeated injections of 
cold or luke-warm water into the nose, and they also 
diminish the foetid smell from the nose and pharynx. 

Fig. 31. 




Tube for Injecting the nostrils. 



368 NASAL DOUCHE. 

If the nose be injected with the ordinary ear syringe, 
the posterior and lateral wall of the pharynx will not be 
touched enough, and in many patients the injection causes 
a severe pain in the forehead, especially if the opening of 
the syringe be directed upward. I have, therefore, caused 
a silver tube to be made, of the same length with the 
catheter, whose end is closed, but the sides are perforated 
with little holes for a short distance from the extremity. 
By means of this instrument we are able to reach the wall 
of the pharynx more conveniently and safely. In order 
that the patient can better apply the syringe himself, the 
outer extremity is bent nearly to a right angle. The in- 
troduction of such a tube is easily learned, even by the 
least intelligent. The water will generally pass out of the 
nose again. Many patients have told me that the head 
felt much freer immediately after the injection, and that 
the noises in the ear were sensibly diminished, and they 
often speak of astonishingly large quantities of mucus 
which have been removed in this manner. 

- 

Weber's nasal douche. — Professor Theodore Weber , of 
Halle, has quite recently suggested a very ingenious 
method of cleansing the nostrils, by which the whole naso- 
pharyngeal cavity may be filled with fluid in a very simple 
manner. In Weber's method we use either a vessel, from 
the lowest part of which proceeds an india-rubber tube, or 
a syphon arrangement consisting of a perforated lead plate 
and a long tube, with a conical nose-piece. Weber very 
properly calls attention to the fact that simple water 
loosens the epithelium, and that it is therefore by no 
means an indifferent fluid to the mucous membranes. 
We should use a little milk with the water, or a weak 
solution of common salt. The patient should avoid any 
great inclination of his head forward, or a severe headache, 



POSTERIOR NARES SYRINGE. 369 

sometimes lasting for hours, may be caused. This results 
from the entrance of water into the frontal sinus. 

(The engraving representing Dr. Clark's ear douche, 
on page 95, will serve to illustrate Weber s apparatus. It 
is known as Thudichum s apparatus, in England and Amer- 
ica, although Weber was undoubtedly the one who first 
suggested its employment. 

In order to use it, the vessel containing the water is 
placed a little higher than the patient's head. The nozzle 
is placed carefully in one nostril, and the patient opens his 
mouth, holding it over the vessel in which the emergent 
stream is to pass. If he breathes gently, the uvula will lie 
against the posterior wall of the pharynx, thus closing the 
upper space from the lower. The water will then run 
around the nostril into which it entered, and pass out 
through the other. 

I have employed this nasal douche to quite an extent, 
but it has been so unpleasant to many patients, and so 
hard to manage, when the patient does not happen to be 
very tractable and intelligent, that I have nearly abandoned 
it, using instead the posterior nares syringe. 

I find that the latter named instrument produces very 
little or no discomfort, and that from three to four 
syringe-fulls will thoroughly cleanse the nostrils and 
pharynx. 

Fig. 32. 




OTTO#REYNDERS.N.Y 

Posterior nares syringe. 

Nasal nebulizer. — I am in the daily habit of using a 
nebulizer upon the mouth of the Eustachian tube, in naso- 
pharyngeal and aural catarrh, and am very much pleased 
with the effects. Mr. Bishop, of London, first advised 

47 



37° 



NASAL NEBULIZER. 



the use of these instruments in aural affections, and claims 
that the spray enters the cavity of the tympanum. A 

Fig. 33. 





Bishop's nebulizer for Eustachian tube. 



ENLARGED TONSILS. 371 

sketch of Mr. B.'s nebulizer is here given. It is a very- 
awkward instrument, and I prefer one made similarly to 
Richardson's local anaesthesia apparatus. The tube is like 
that of a Eustachian catheter, and is introduced the same 
way. A solution of common salt, of tincture ferri sesqui- 
chlorid, chlorate of potash, or any of the agents employed 
on inflamed mucous membrane, may be used through the 
nasal or Eustachian nebulizer. St. J. R.) 

Removal of the tonsils. — If the tonsils be abnormally 
large, they must be removed, or the treatment will have 
no lasting effect. Hypertrophied tonsils, if not them- 
selves the seat of frequent inflammation and abscesses, 
retain the chronic congested condition of the pharynx by 
their presence, since they act as foreign bodies, and pre- 
vent the normal action of the muscles of the throat. 
They also push the broad portion of the soft palate up- 
ward, and thus, but not in a direct manner, as is generally 
>elieved, press the anterior lip of the Eustachian tube 
igainst the posterior. I have also seen improvement in the 
Learing in recent cases of aural catarrh, immediately after 
:he removal of the tonsils, and in children; but even in 
>ld cases the chronic catarrh of the pharynx is very much 
improved, and it loses the tendency to increase the affec- 
:ion of the ear. 

I also advise you to exercise the tonsils when they are 
large, even if they have not as yet had an evil effect upon 
:he organ of hearing. Setting aside the fact that a re- 
loval will guard the ear from any evil consequences, 
enlarged tonsils are a hindrance in respiration, and thus 
iave a considerable effect on the whole constitution, 
especially on the development of the chest. They may 
ie excised with Fahnestock's instrument or Tonsillo- 
:ome. You should remove only the portion of the tonsil 
r hich reaches out in front of the arch of the palate, since, 



372 ENLARGED TONSILS. 

without this precaution, you may have severe hemorrhage, 
which cannot be checked. The end of the tonsil being 
thus cut off, the gland will afterward shrink away. In- 
cisions and scarifications are only useful in acute cases, 
and in the evacuation of abscesses. Pencilling with iodine, 
nitrate of silver, etc., even when persisted in for weeks, 
according to my experience, produces no result. 

(Powerful caustic^ may be introduced on an instrument 
adapted to prevent them from slipping off before reaching 
the part to be cauterized, and a large portion of the tonsil 
thus removed. The appliance used consists essentially of 
a spatula, containing on its extremity a receptacle for the 
caustic, which is opened when the surface of the tonsil is 
reached, by the withdrawal of a sliding cover which works 
from the handle of the instrument. St. J. R.) 

It is at times of great advantage to cut off an elongated 
and hypertrophied uvula, which frequently causes very 
severe attacks of coughing, occurring at night especially. 
We may draw it forward with a polypus forceps, which acts 
at the same time as a spatula, and cut it off with a pair 
of scissors. 

The general condition of the patient. — In consider- 
ing this, I may remark, gentlemen, that if I were to go 
into the greatest detail of description, I should not be 
able to enumerate all that we are required to consider in a 
case of chronic catarrh, but I will be very brief in what I 
have to say, trusting that you will carefully consider each 
case by itself. 

Make each patient attentive to every influence which 
acts favorably or unfavorably on his condition. If a per- 
son works for a whole day with a bended head, in an over- 
heated office or counting room, perhaps never enjoying 
more than half an hour's fresh air in a week, in the eve- 
ning smokes and drinks in a reeking restaurant or bar- 



CONSTITUTIONAL TREATMENT IN CATARRH. 373 

room, and sleeps in a small, unventilated chamber until 
very late in the morning, he has very many opportunities 
to develop an aural and pharyngeal catarrh to its utmost, 
and you will never be able to lessen the disease, whatever 
you may do. Fresh air, and exercise in it, but with an 
avoidance of cold mornings and evenings, clothing adapted 
to the weather, woolen or silk next to the body in winter, 
care that the feet are dry and warm, an avoidance of what- 
ever interferes with the free circulation of the blood, viz., 
tight articles of dress, costive bowels, and long-continued 
sitting in a bent position, are very important matters in 
this class of cases. 

Treatment by the so-called "whey cure," the "grape 
treatment," and the use of mineral waters, is often of 
great value in chronic catarrh, especially after, and in con- 
nection with, local treatment. Without the latter we can 
never stop the steady progress of the disease. The most 
energetic treatment by baths and drinking of mineral 
waters, cannot be remotely compared to the local treat- 
ment. The use of salt baths is most frequently indicated. 

Of internal remedies, cod-liver oil, especially with an 
addition of oil of turpentine, seems to lessen the tendency 
to catarrh the most; a half to one scruple of turpentine 
may be used to an ounce of the oil. We may somewhat 
disguise the taste by the addition of a little oil of cinnamon 
or sassafras. 

Of course where there is a decided syphilitic or scrofu- 
lous basis in an affection of the ear, the constitutional 
disease should be appropriately treated. Yet in these 
cases the local treatment should never be neglected. 

It is very important, in the management of aural and 
pharyngeal catarrh, to take good care of the skin. In the 
cold weather a warm bath should be taken quite often. It 
is better that baths in this season should be taken in the 
patient's own house, in order to avoid taking cold after 
them. In the summer the patient may bathe in cold run- 



374 CONSTITUTIONAL TREATMENT IN CATARRH. 

ning water, taking care that the ears are protected from the 
entrance of the water. The body should be well rubbed 
after bathing. 

(Too frequent and prolonged bathing is a common cause 
of tubal catarrh in young persons. I have seen so many 
little patients who have become deaf after excessive bath- 
ing, that I am in the habit of warning parents from allow- 
ing the prolonged bathing and "ducking the head," so 
common among boys. St. J. R.) 

Up to this time I have observed that patients have often 
become worse after the use of sea baths, but I have seen a 
residence on the sea coast, with use of warm sea water baths 
in doors, do great service, especially in young and torpid 
individuals. 

There are some patients upon whom baths, when taken 
in the morning, act unpleasantly, that is, excite trouble in 
the ears. 

Although the hydropathic or water cure treatment, con- 
ducted properly, especially the cold rubbings, may be able 
to do very much in the way of hardening the skin, a 
shower bath early in the morning, which many patients 
believe to be a panacea for the evils attendant upon an im- 
proper mode of life, often does a great deal of harm to the 
ears. The worst cases of thickening of the mucous mem- 
brane of the cavity of the tympanum not unfrequently 
result from its use. 

(So-called Turkish and Russian baths are very much in 
vogue in New York as a panacea for catarrh, rheumatism, 
etc. They are efficient cleansers of the body, and, care- 
fully employed, are good adjuncts in the treatment of 
aural catarrh, but they are not indispensable, and can 
never be substituted for local treatment. 

The diet should be very carefully regulated in the treat- 
ment of catarrh. Hot drinks, or very cold ones, should 
be avoided, and nourishing, but non-stimulating food 
recommended. St. J. R.) 



LECTURE XXII. 

ACUTE OTITIS MEDIA, OR ACUTE PURULENT CATARRH. 

Different forms of aural catarrh; symptoms , prognosis and 
treatment of acute otitis media; it is often overlooked, or not 
properly regarded; the different forms of deafness in typhus 
and typhoid fever; manner in which perforation of the 
membrana tympani occurs, 

PARACENTESIS OF THE MEMBRANA TYMPANI. 

Historical; method of performance ; its employment for the 
evacuation of pus, mucus and blood from the cavity of the 
tympanum, in acute myringitis and adhesion of the Eus- 
tachian tube; its value as a method of diminishing deafness 
and noise in the ears; difficulty in maintaining the opening. 

Gentlemen: The inflammation of the mucous mem- 
brane of the middle ear, which we have up to the pre- 
sent time considered, was simple or mucous catarrh. A 
great increase of the catarrhal process leads, as is well 
known, to excessive developments of free cell formation, 
in other words, to suppuration in the inflamed mucous 
membrane. Observations upon the living and dead sub- 
ject teach us that purulent catarrh also occurs in the mid- 
dle ear, although much less often than mucous catarrh. 
There are two forms — the acute and chronic. The in- 
flammatory product, besides containing the puriform ele- 
ment, also contains mucus and epithelial masses, since, as 
a rule, the inflammatory products of mucous membrane 
are of a mixed character, and there are a number of inter- 
mediate forms between the two different sorts of inflam- 



376 ACUTE PURULENT CATARRH. 

mation. The name purulent or mucous catarrh only 
indicates that either one product or the other is in excess, 
without completely excluding the other. 

Whether croupic or diphtheritic inflammations also 
appear on the mucous membrane of the middle ear, I do 
not know. I have not as yet observed any such cases. I 
examined in two instances the middle ear of children who 
died from laryngeal croup. In one case the membrane 
was only hyperaemic, in the other it was greatly swollen 
on each side, and the cavity of the tympanum was full of 
pus. I did not find a trace of fibrinous exudation in the 
auditory canal or cavity of the tympanum. (Dr. Robert 
Wreder? reports eighteen cases of otitis media diphtherica 
which appeared in the course of scarlet fever complicated 
by naso-pharyngeal diptheritis. St. J. R.) 

Acute purulent catarrh of the middle ear, or acute 
otitis interna. — We often find evidences of this disease 
on the dead body, in children. Of this I shall speak again. 
We then observe it as a participant and consequence of 
the exanthemata, measles, scarlet fever, and small-pox, also 
in typhus fever and phthisis pulmonalis. It also occurs 
from the exacerbation of a chronic inflammation of long 
standing, to an acute form, especially when a perfora- 
tion of the membrana tympani exists. Under very unfa- 
vorable circumstances of the patient, or improper treat- 
ment, acute simple catarrh may be developed into the 
purulent form. Acute purulent catarrh also occurs in 
weakly, scrofulous constitutions, which are disposed to 
purulent formations, from injuries, or influences which in 
healthy persons would have only caused a simple catarrh. 

Symptoms. — This affection has heretofore been de- 
scribed by most authors as an acute inflammation of the 

1 Monatschrift fiir Ohrenheilkunde, No. 10. 



ACUTE PURULENT CATARRH. 377 

membrana tympani. The symptoms are very similar to 
those in acute simple catarrh, which has been previously 
described, but they are much more severe, and the general 
condition of the patient is much more disturbed. Cases 
exceptionally occur, however, where an abscess in the 
cavity of the tympanum runs its course, and leads to per- 
foration of the drum, without causing any pain or serious 
disturbance of the system. The pain, which is generally 
very intense, extends from the ear over the whole side of 
the head, and increases with every movement; it becomes 
unbearable if the patient walks on the pavement or other 
hard substance. The immediately neighboring parts are 
generally somewhat infiltrated with serum, somewhat 
swelled and sensitive. There is also a severe burning 
feeling felt in the depth of the ear in most cases. The 
febrile condition is so great as to often extend to delirium 
and stupor. 

As a rule, such symptoms as these, occurring in one of 
the exanthemata, or in typhus fever, and which can only be 
referred to the ear, are but little observed, in consequence 
of the danger from the general condition of the patient. 
In their beginning probably they are never referred to the 
correct source. The aural surgeon does not, therefore, 
often see these cases in their incipient stages, if we except 
those cases in which an old purulent catarrh, with perfora- 
tion of the membrana tympani, suddenly becomes acute. 

The error to which I called your attention in a former 
lecture — that is, that of confounding an acute mucous 
catarrh with an inflammation of the brain, mav be also 
fallen into here, for there is always, in acute purulent 
catarrh, a hyperemia of the dura mater lying over the 
petrous portion of the temporal bone, and a proportion- 
ate effect on the sensorium. So long as no purulent dis- 
charge occurs, the general condition of the patient prevents 
any particular attention from being paid to the ear, and 

4 8 



378 ACUTE PURULENT CATARRH. 

the delirious or somnolent patient is in no condition to 
indicate the seat of his sufferings. 

The common result of the morbid process is perfora- 
tion of the membrana tympani, with which the pain is 
very much diminished, and a purulent discharge takes 
place for the first time, if there has not already been a 
participation of the external auditory canal in the process. 
There is often developed, at the same time with the puru- 
lent inflammation of the cavity of the tympanum, an acute 
otitis externa, proportionate to the intense hyperaemia in 
which all the structures are found. According to several 
sections which have been made in cases where death oc- 
curred from typhoid fever, the labyrinth also appears to be 
in a state of congestion. 1 

In cases where a chronic otorrhoea, with perforation of 
the membrana tympani, increases to an acute inflammation, 
the discharge is often suddenly lessened, or disappears 
entirely. This symptom is often incorrectly interpreted. 
Such an acute inflammation does not occur because as a re- 
sult of a certain treatment, or of any accidental coincident 
injury (cold, a blow on the head), the secretion has been 
diminished, or, as some are accustomed to express them- 
selves, "driven in," but, on the contrary, the discharge, 
which has been previously profuse, becomes less from 
the occurrence of an acute inflammation of the membrane 
which has previously furnished the secretion, just as we 
may see the secretion diminished in a chronic catarrh 
which has suddenly gone on to an acute form. 

Simple chronic catarrh after typhus and typhoid fever, 

1 The best brochure on diseases of the ear occurring in typhus fever, is from Dr. Hermann 
Schivarfze. See "Deutsche Klinik," 1861, Nos. 28 and 30. According to Dr. S., there 
are three processes in this disease that cause ear affections. 

1. Purulent catarrh of the cavity of the tympanum. 

2. Catarrh of the pharynx, with closure of the pharyngeal end of the Eustachian tube. 

3. Cerebral deafness, due, perhaps, to the poisoning of the blood. According to Sebert 
the deafness in typhus and typhoid fever may result from the general depression of the 
nervous system. 



ACUTE PURULENT CATARRH. 379 

as in scarlatina and roseola, is quite common, and it is 
possible for it to run its course without any perforation of 
the membrana tympani, leaving only a swelled and con- 
gested condition of the cavity of the tympanum behind. 
The more dangerous purulent catarrh may also run its 
course, and leave no other residue. The fact should also 
not be overlooked, that the milder and simpler forms of 
aural catarrh also occur after these diseases. 

The most severe and dangerous form of the disease of 
which we are now speaking, is that in which there is such 
a power of resistance on the part of the membrana tym- 
pani that the abscess cannot be discharged by its perfora- 
tion. There are a number of such cases on record, where, 
after the most terrible agony and severest symptoms, the 
inflammation extended to the membranes of the brain, and 
death quickly followed. Such cases, especially, can 
scarcely be correctly interpreted, unless the ear is exa- 
mined. They, perhaps, occur more frequently than has 
as yet been demonstrated on the cadaver. The perfora- 
tion of the membrana tympani, therefore, may be some- 
times considered as a favorable turn in the condition of 
things/ Yet, even if an exit be thus formed for the pus, 
the disease may still go on to a fatal result by a continua- 
tion of the suppurative process upon the important adja- 
cent parts. This occurs most often in children, after one 
of the exanthemata. Later on in these lectures we shall 
describe such a case in detail. 

The objective appearances in the ear, in acute internal 
otitis, are similar to those of a severe case of simple acute 
catarrh. The plane of the membrana tympani is altered 
by the collection of pus behind it, which bulges or 
pushes out some parts of its surface. Single vessels are 
not often to be seen, but a general red appearance, indi- 
cating the hyperemia of the mucous surface of the mem- 
brane, is mingled with its dull grey color. Sometimes 



380 ACUTE PURULENT CATARRH. 

single red spots (extravasations) may be seen on it. In 
very acute cases the membrana tympani is sometimes, 
before the perforation, of an even red color. The swell- 
ing of the membrane is usually very great. The osseous 
part of the auditory canal is generally also affected. In 
severe cases the mastoid process is painful and sensitive 
on pressure, and has an infiltrated, shining, red appear- 
ance. Examination of the pharyngeal mucous membrane 
often reveals a considerable swelling and redness, and the 
Eustachian tube will be found impermeable, except when 
the catheter is used. 

Prognosis. — This is more unfavorable than in the acute 
form of simple catarrh. Very few physicians can bring 
themselves to pay the least attention to the ear, in the 
constitutional diseases of which we have been speaking. 
Yet they are the very ones in which its functions are most 
apt to be disturbed. Never are affections of the ear so 
completely disregarded and placed in the background as in 
those diseases which confine a patient to bed. How many 
trouble themselves about the consideration of the ear in 
typhus fever, in tuberculosis, or in scarlet fever? An Ame- 
rican surgeon (Professor Edward H. Clarke, of Boston) 
says, in an excellent article on "Perforation of the Mem- 
brana Tympani, its Causes and Treatment: "' "60 neces- 
sary is a careful attention to the ear, during the course of an 
acute exanthema, that every physician who treats such a case, 
without careful attention to the organ of hearing, must be de- 
nominated an unscrupulous practitioner ." How severe this 
must sound to the most of German physicians! Certain 
it is, that if every physician were to inform himself of the 
condition of the ear and the hearing, as well as of the skin 
and kidneys, pulse and bowels, many a child would not 
become deaf and dumb, and many incurable cases of deaf- 

1 American Journal of Medical Sciences, January, 1858. 



ACUTE PURULENT CATARRH. 38 1 

ness, and many life-long otorrhoeas would be avoided. 
There are such a number of acute diseases in which the 
ear is also affected, that the physician should always exa- 
mine as to its condition, without waiting for the patient 
to announce his affection. 

Even with the most careful attention, and when the 
special symptoms lead us to take every care for the ear, 
we are sometimes unable to prevent the perforation of the 
membrana tympani. There will not be very much lost 
in this event, however, and there is still a wide field left 
for surgical assistance, in preventing the otorrhoea from 
becoming chronic, and from leading to evil consequences. 

Purulent catarrh of the cavity of the tympanum is cer- 
tainly the most frequent cause of perforation of the mem- 
brana tympani. This perforation may occur from the 
pressure of the secretion which is constantly collecting. 
More frequently, however, a rupture of the inflamed, 
softened, and relaxed membrane, occurs as a consequence 
of a sudden variation of the quantity of air in the ear. 
Such a change has the more effect, because the amount of 
air in the ear is very much lessened, in these cases, by the 
filling of the cavity of the tympanum, and of the mastoid 
process, by the swelled mucous membrane. We find, 
therefore, that the air first passes suddenly through the 
ear in sneezing or blowing the nose. We then observe in 
the membrana tympani a linear rupture, and not a round 
hole, such as results from the bursting of an abscess from 
pressure. Perforation certainly occurs much more rarely 
as a consequence of inflammatory disintegration, or ulcer- 
ation, in myringitis or external otitis, than it does from 
suppuration of the middle ear. Perforation may also 
occur from the simultaneous action of various causes. 

Treatment. — This must of course be decidedly anti- 
phlogistic. We must practice local depletion according to 



382 ACUTE PURULENT CATARRH. 

the general condition of the patient — by placing a number 
of leeches around the meatus. We should also fill the 
ear with warm water very often. Free evacuation of the 
bowels is scarcely to be dispensed with. 

(The use of the aural douche figured on page 95 of this book, is 
the best method of filling the ear very frequently with warm water. I 
have lately used it for this purpose, and I have given it into the hands 
of patients suffering from acute inflammation of the ear, who have 
derived great comfort from it. The little cup may be placed on a 
mantel or a table, just a little higher than the patient's head, and then 
the stream of warm water be conducted into the ear. St. J. R.) 

When the otitis, as is often the case in measles and 
scarlet fever, is accompanied by considerable inflammation 
of the pharynx, or this has been the origin of the whole 
process, the greatest attention must be paid to it. You 
may apply cold water to the neck, or, better, large, fre- 
quently-changed, flax-seed poultices; cause the patient to 
gargle frequently, and, if possible, cleanse the naso- 
pharyngeal cavity by injections, and, if necessary, cauter- 
ize the throat with the nitrate of silver. 

It is, of course, extremely important, in this latter class 
of cases, to secure for the pus collecting in the cavity of 
the tympanum, its natural outlet, through the Eustachian 
tube. We therefore employ the air bath, or douche, at an 
early period, either by means of the catheter, or Politzer's 
method. This latter should be employed with only a slight 
amount of force. It is best to employ it by blowing 
through a gutta-percha tube placed in the nostril. 

You must not consider this as too energetic treat- 
ment, but remember that perhaps the life and happiness 
of the patient depend upon your promptness and care. 
Aural inflammation, in scarlet fever and measles, furnishes 
the greatest number of the inmates of deaf and dumb 



ACUTE PURULENT CATARRH. 383 

asylums, as well as a large proportion of all cases of deaf- 
ness of a high grade, in consequence of the readiness of 
the ear to participate in the exanthemata, and also, as we 
must confess, from indifference of the physician to this fact. 

In cases where the inflammation, and formation of pus are 
considerably advanced, and where we shall probably not be 
able to prevent the perforation of the membrana tympani, 
or perhaps this result is wished for, we may encourage the 
suppuration by the application of warm poultices to the 
ear — which are to be omitted as soon as perforation has 
occurred — or, a paracentesis of the membrana tympani may 
be performed, which will be better. If a portion of the 
drum bulges forward, on account of the pus collected be- 
hind it, you may make the paracentesis at this point, in 
other cases on the posterior and lowest part of the mem- 
brane, because the cavity of the tympanum is here the 
deepest. 

In one case I was able to see the sudden improvement 
which occurred after such a paracentesis, without any dis- 
charge of pus. A woman working in a factory, who was 
twenty-seven years of age, applied to me, after having 
suffered for ten days from a very intense pain in the ear, 
and a temporary otorrhcea. I examined the membrana 
tympani, and observed a spot, like a blister from a burn, 
about as large as a pea, such a one as you may see if the 
patient has burned the membrane by an ear wash that has 
been too warm. This could not have happened in this 
case, since the patient had put nothing at all in the ear. 
The remaining portion of the membrana tympani had a 
dense, reddish grey appearance. There was great pain in 
the ear and the mastoid region, the latter being reddened, 
the temperature increased, besides being sensitive on press- 
ure. I opened the blister immediately, with an instrument 
such as is used in paracentesis of the cornea, and evacuated 
a drop of serum. At this moment the patient breathed 



384 PARACENTESIS OF MEMBRANA TYMPANI. 

freer, and declared that the pain had almost entirely disap- 
peared, and what was in the highest degree remarkable, the 
mastoid process was less sensitive to pressure, and the 
patient was enabled to open the mouth, which she was 
before unable to do. 

In another case of acute catarrh of the cavity of the 
tympanum, where I performed a paracentesis of the mem- 
brana tympani, the influence which the operation had upon 
the mobility of the lower jaw was remarkable. The pa- 
tient had been unable for several days to open his mouth, 
and complained of spasmodic contraction of the muscles 
of mastication on the affected side. In a few hours after 
the operation all these difficulties were removed. 

Paracentesis of the Membrana Tympani. 

This is the proper place in which to submit some 
general considerations as to the operation of paracentesis 
of the drum, the indications for its performance, and its 
value. 

Historical. — This operation was first performed on dogs, 
by Willis and Valsalva, and subsequently by Cheselden. It 
was first performed on the human subject by a peripatetic 
miracle worker named Eli, about the year 1760, in Paris. 
Himly introduced the operation into Germany in 1797, 
when he demonstrated the method of its performance on 
the human cadaver, and living dogs. Himly first performed 
it on a deaf person in 1806. Sir Astley Cooper performed 
the operation in England in 1801. It was very much 
performed in the first ten years of this century, until the 
profession became convinced of the rarity of any perma- 
nent benefit from it. 

Subsequently it was very much practiced in France by 
Deleau, Meniere, and Bonnafont, but it was very seldom 
undertaken in Germany, until very recently — in 1863, whenl 



PARACENTESIS OF MEMBRANA TYMPANI. 385 

Joseph Gruber, of Vienna, again recommended the ex- 
cision of a portion of the membrana tympani, "myringo- 
dectomy," as a remedy for impairment of hearing, and 
tinnitus aurium. H. Schwartze has very lately given a very 
excellent historical and clinical- sketch of this subject in 
the Archiv fur Ohrenheilkunde, B. II, 1 and 4, III, 4. 

. Operation. — For the performance of the operation we 
may use a needle, such as is used in a paracentesis of the 
cornea, an explorative trocar, or a slightly curved cataract 
needle. With this latter we may also cut out a piece from 
a thickened and resisting membrana tympani. Many of 
the complicative instruments devised for this operation, 
seem to be at least superfluous. 

It is usually very easy to make an opening in the 
drum. There is generally a very considerable amount of 
pain, which lasts for a very short time, however. Accord- 
ing to Schwartze, when a portion of the membrana tympani 
bulges forward like a little sac, the operation causes no pain 
whatever. Very severe reaction follows a paracentesis in 
rare cases. 

The value of this operation, when there is an acute fill- 
ing up of the cavity of the tympanum with pus, is unde- 
niably the same as that from opening an abscess in any 
other part of the body. We may thereby save the patient 
much pain, and have a cleaner and slighter loss of sub- 
stance than when we leave the opening to nature. This 
latter fact is of particular value in relation to the membrana 
tympani, because the artificial opening heals more certainly 
and readily than a spontaneous evacuation of an abscess 
of the middle ear, which easily leads to great relaxation 
or even necrosis of the tissue, so that the healing of the 
, opening is at least retarded. 

Besides, the prognosis for the restoration of hearing will 
of course be more favorable, the shorter the period during 

49 



386 PARACENTESIS OF MEMBRANA TYMPANI. 

which the middle ear has been filling up, and the sooner 
we succeed in removing the hyperaemic swelling and puffi- 
ness of the mucous membrane. Of course in empyema 
of the cavity of the tympanum, the air douche or bath, 
and the evacuation of the secretion through the mouth of 
the Eustachian tube, are of value, but in severe cases, 
when the air douche may produce very little or only a tem- 
porary benefit, on account of the great swelling of the mem- 
brane of the tube, paracentesis of the membrana tympani 
must be a useful means of treatment. The operation is 
still more important where the membrana tympani has 
become thickened on account of previous disease, and 
hence the probability of a voluntary opening is very much 
lessened. Such cases not unfrequently end in death. As 
has been already said, a paracentesis of the membrana 
tympani, done at the proper time, will prevent the inflam- 
mation from extending to the membranes of the brain, 
and thus may actually save life. 

As we have seen, Schwartze recommends this operation 
in simple acute catarrh, when the accumulation of mucus 
is so great that the membrana tympani is bulged out like 
a little vesicle. Such a bulging out is generally found in 
the posterior half, and is most distinctly seen after the air 
bath. The membrane is yellow from the shining through 
of the secretion ; it fluctuates on contact with a probe, and 
is not in the least sensitive. In consequence of the extreme 
tenacity of the secretion, the air douche is not sufficient 
to drive it out through the tube, and its long continuance 
in the cavity of the tympanum may easily induce perma- 
nent changes in the latter. Then, however, a simple punc- 
ture is not sufficient, but an incision of from one to two 
lines in length should be made. Schwartze decidedly dis- 
approves of the operation when there is a slight amount of 
tenacious mucus in the cavity of the tympanum, because 
he fears that these small collections are never evacuated 



PARACENTESIS OF MEMBRANA TYMPANI. 387 

through the opening, and that "very severe reaction often 
occurs in such cases after the paracentesis ; active inflam- 
mation, which terminates in suppuration, and often with 
considerable diminution in the acuteness of hearing." 

Paracentesis of the membrana tympani is also very use- 
ful, according to Schwartze, cc in certain cases of acute 
inflammation of the membrana tympani, where, in a very 
short time, a very great swelling of the usually dark 
bluish red tissue occurs, chiefly and greatest in the posterior 
and upper quadrant, and when, in spite of the use of other 
remedies, there is very obstinate and severe pain. It 
quiets the pain and thus shortens the course of the affec- 
tion. 

Paracentesis is scarcely practicable for the evacuation of 
blood which is in the cavity of the tympanum, because 
the blood will be coagulated by the entrance of atmo- 
spheric air through the Eustachian tube. An artificial 
opening of the membrana tympani may cause suppuration 
to occur, while experience teaches that the blood, left to 
itself, is gradually absorbed. 

When there is an impermeable stricture of the mouth of 
the tube, that is, a true adhesion of the walls of the canal, 
another indication is furnished for the performance of a 
paracentesis of the drum. This indication is not very 
important, for the following reasons: On the one hand, 
according to the observations as yet made, such an adhe- 
sion seems to be an extremely rare occurrence. On the 
other, it is extremely improbable that it can exist for any 
length of time, without very great pathological changes 
taking place in the middle ear, from the retention of the 
secretion, and the permanent increase in the hydrostatic 
pressure in the cavity of the tympanum and the labyrinth^ 
which would prevent any result from the operation. 

In those cases where, from repeated examination with 
the catheter and bougie, we must believe that the existence 



388 PARACENTESIS OF MEMBRANA TYMPANI. 

of an adhesion of the walls of the canal is very probable, 
we would certainly be justified in an explorative puncture 
of the membrana tympani. 

The cases as yet seen are collected by Lindenhaum in the " Archiv 
fur Ohrenheilkunde," 1, s. 295. 

(According to Lindenbaum there are four authentic cases of clos- 
ure of the pharyngeal orifice of the tube, usually by cicatrization 
from syphilitic ulcers. The cases recorded in the older text books 
give no evidence that an actual closure of the tube existed, but what 
we would now call impermeability of the tube to air at the times 
when the Eustachian tube normally opens, i. e., during swallowing, 
violent respiration, etc. St. J. R.) 

Schwartze made a paracentesis in one case, in which, although the 
rhinoscope could not be used to verify the diagnosis, he supposes the 
walls of the tube to have been adherent. In three days the opening 
had closed, and the improvement to the hearing which immediately 
followed the operation, was gone. 

Paracentesis of the membrana tympani may also be of 
value in cases where the impairment of hearing depends, 
at least in part, on thickening and inelasticity of the 
membrana tympani, which have thus become an impedi- 
ment to the conduction of sound. 

Whether this be really the principal cause of the im- 
pediment, or whether it depends on a thickening of the 
membranes of the fenestra?, we cannot determine in ad- 
vance. As Wilde has already said, very frequently the 
thickening which we do see on the membrana tympani, is 
only a part of the common thickening and disorganization 
of the whole membrane of the middle ear, which we do 
not see, and under such circumstances a hole in the mem- 
brana tympani can cause no benefit to the hearing. If, 
however, the thickening of the membrana tympani de- 
pends on an hypertrophy of the cutis, and of the epidemis, 
as is quite frequently the case after chronic inflammation 
of the membrana tympani and the auditory canal, appro- 



PARACENTESIS OF MEMBRANA TYMPANI. 389 

priate instillations, and pencillings of the parts, will gene- 
rally lessen the thickening very much, as has been already 
mentioned. I have before shown you that a very con- 
siderable amount of calcareous degeneration may exist 
on the membrana tympani in connection with a good 
hearing power ; hence the existence of these calcareous 
degenerations are never of themselves a sufficient indication 
for the performance of a paracentesis of the drum of the 
ear. 

Joseph Gruber 1 adds to the indications for this opera- 
tion, "anomalous adhesions of the structures of the mid- 
dle ear (if these anomalies be positively recognized), in 
order to prepare the way for the breaking up of these 
adhesions." With Scbwartze, he considers it possible that 
this indication may be of value in the future. There are, 
however, as yet, no sufficient proofs of the value or per- 
manence of the result. 

Wilde first proposed paracentesis of the membrana 
tympani, as already stated, for very troublesome tinnitus 
aurium. He suggested it in consideration of the fact that 
it was only rarely that we met with persistent and very 
troublesome tinnitus in a case where the membrane was 
perforated. Schwartze, following this indication, has per- 
forated the drum very many times without any decided 
or permanent result. In one case, only, was the noise 
considerably lessened after the cicatrization of the portion 
that had been incised. In two cases where I perforated 
the membrane on account of very great noise in the ear, 
the relief was very great, but it disappeared completely as 
•soon as the opening had closed. 

The short duration of the improvement to the hearing 
is the worst feature in this operation. It is usually very 
easy to perform, but its value in improving the hearing 

1 Allgemeine Wiener Mediz, Zeitung, 1863, Nos. 39-43; 1864, Nos. 13-165 also in 
Archiv fur Ohrenheilkunde, II, s. 58. 



390 PARACENTESIS OF MEMBRANA TYMPANI. 

and lessening the noise in the ear, whatever it may be, is, 
soon lost. It seems, as yet, impossible to devise any way 
by which an artificial opening in the membrana tympani, 
or even a loss of substance, can be kept from closing up 
again. 

It is frequently as difficult to keep an artificial opening 
from closing, as it is to close one that has been produced 
by disease, and which has existed for a long time. We 
may cauterize the edges of the aperture, cause the patient 
to practice the Valsalvian method of inflating the ear ; 
we may place bougies, little tubes and the like, in the 
opening, and yet the great regenerative power of the mem- 
brane of the middle ear will generally laugh at all these 
attempts to maintain a perforation. 

Bonnafonf has performed paracentesis twenty-five times 
within three years on one patient, without ever succeeding 
in keeping an opening longer than some months. 

Among the many reports of favorable result from this 
operation, none of them can be said to give any sufficient 
evidence of its real value (of course I am now speaking of 
the paracentesis performed in cases of chronic catarrh, and 
not of those where it has been done as the opening of an 
abscess), unless the patients have remained for a long time 
under observation after the operation. Most of the 
histories are, in this respect, imperfect, and I must there- 
fore fully coincide with Schwartze when he says that, up 
to the present time, "it is only in very rare cases that a 
permanent success has been seen by trustworthy observers." 

If a case occurred to me where it was extremely neces- 
sary to maintain an opening in the membrana tympani, I 
would make a large flap in the membrane, and attempt to 
cause it to adhere by pressure or attachment to a portion 
of the cavity of the tympanum, or auditory canal, whose 

i Traite theor. et prat, des maladies d' Toreille, Paris, i860, p. 375. 



PARACENTESIS OF MEMBRANA TYMPANI. 391 

surface has been previously freshened. It is in a manner 
similar to this, that we find that natural perforations of 
the membrana tympani are formed, which resist all attempts 
to heal them up. 

(Voltolini* of Breslau, has recently perforated the membrana tym- 
pani by means of the galvano caustic apparatus. The operation can 
be done without chloroform, it causes no pain, and it is hoped that 
the opening made will be permanent. In the case in which Voltolini 
performed the operation, the deafness was absolute. It occurred 
after continued fever, during convalescence, and there were very 
troublesome head symptoms, heaviness, tinnitus, etc. The latter 
was greatly relieved, the deafness, however, was not at all improved, 
or to a very slight degree. 

Dr. Wreden* of St. Petersburg, excises the handle of the mal- 
leus in cases of sclerosis of the middle ear, with deafness and tin- 
nitus. He has devised an instrument for the operation. St. J. R.) 

1 Monatsschrift fur Ohrenheilkunde, Vol. I, No. 3. 
a L. C, Vol. II, No. 2. 






LECTURE XXIIL 

PURULENT AURAL CATARRH IN CHILDREN. 

Up to this time chiefly known through pathological study ; an 
attempt at an explanation, and its practical value; Dr. 
Wreden s cases. 

Gentlemen: I am about to speak to you of a form 
of purulent catarrh which I am acquainted with only from 
post mortem evidences, and which, as seen in the living, 
I must leave to those who have sufficient opportunities to 
study the diseases of children. In the course of my exa- 
minations of the normal and pathological anatomy of the 
ear, I came accidentally on a peculiar condition in the ears 
of very young children, which excited my attention the 
more, because I observed it so frequently, that is, in the 
greater number of infant subjects of which I have had the 
opportunity of making a post mortem section. I examined 
forty-eight petrous bones belonging to twenty-five child- 
ren, and when I except one case of caries of the temporal 
bone, on each side, I found, in the remaining forty-six 
bones belonging to twenty-four children, the middle ear 
normal thirteen times in seven children, while the remain- 
ing thirty-three ears of seventeen children were affected 
with purulent catarrh of the middle ear. The cavity of the 
tympanum, the upper portion of the Eustachian tube, and 
the cells of the mastoid process, were filled with a green- 
ish yellow substance, which was sometimes creamy, again 
a gelatinous fluid, that looked like pus, which it proved 



INFANTILE AURAL CATARRH. 393 

to be, under the microscope. It appeared composed of 
roundish cells, with a quadrilateral nucleus or nuclei, 
which were often visible without the use of acetic acid. 
The clouded contents of the cells cleared up on the use 
of the acid, but they very frequently contained little fat 
granules. These collections of pus filled the whole of the 
space which the swollen mucous membrane had left. The 
mucous membrane was always in a very hyperaemic condi- 
tion, and occasionally there was a net-work of very delicate 
vessels. The membrane was, as a rule, so hypertrophied 
that the ossicula auditus were imbedded in it, and their out- 
lines were scarcely to be made out. The mucous membrane 
of the membrana tympani also appeared slightly infiltrated, 
and covered over with a net-work of vessels. The mem- 
brane was never perforated or in a state of ulceration. 1 

Scbwartze found in several cases, together with similar appear- 
ances, hyperaemia in the membranous labyrinth, and once even pus 
in the cochlea, so that the structure of the membrane of the lamina 
spiralis was completely destroyed by the surrounding pus. 

With these appearances there also appeared, in eight 
cases, and always in those where the contents were of a 
gelatinous consistency, peculiar red bodies, from the size 
of the head of a pin to that of a hemp seed, which were 
quite hard to the touch, and were firmly attached to the 
mucous membrane. On nearer examination they proved 
to have a very vascular cortex, and an internal structure, 
sometimes consisting of granular-like fat, again of cells. 
All other explanations are wanting as to the nature and 
origin of these puzzling bodies, to which I know no 
analogous structures. 

The bodies of which the examination were made were 
taken without choice, as they were furnished, during the 
space of three years and a half, partly from the city and 

i Archiv fiir Ohrenheilkunde, I, s. 203. 

5° 



394 INFANTILE AURAL CATARRH, 

partly from the lying-in institution, to the pathological de- 
partment of the Medical School in Wiirzburg. The 
youngest child was seventeen hours old — the oldest, one 
year. Of the children with a normal middle ear, two 
were fourteen days old, one seventeen hours, one four 
days, and the remaining three, six and eleven months, 
respectively. The bodies were often such as were fur- 
nished to the students for the study of normal anatomy, 
since in the post mortems which had been held, the imme- 
diately affected portions were the only parts examined. 
Twelve were of this class. The other post mortem appear- 
ances were various, corresponding to the condition in life 
of these poorly-cared-for and half-starved children. The 
diseases of which they died were atrophy, inflammation of 
the bowels, partial collapse of the lung, and bronchitis. 
There was venous hyperemia of the coverings of the brain, 
and congestion of the brain substance, in almost all of the 
observed cases. In those cases in which there was no pus 
in the cavity of the tympanum, there were no other patho- 
logical appearances. Thus much for the facts. 

Although the number of petrous bones thus examined 
is not very large, it is sufficiently so — since the subjects 
were taken without choice, and during quite a large space 
of time — to allow us to say that the middle ear of young 
children, when examined post mortem, is very often found 
in a condition of purulent catarrh. 

Now, gentlemen, what shall we conclude from the de- 
velopment of these very unexpected facts? Can we 
believe that we are here dealing with a normal and physio- 
logical, and not a pathological condition? Masses of pus, 
when found in a normal atmosphere, an hyperaemic, 
greatly swelled mucous membrane, instead of a smooth, 
thin, and moderately vascular one, form a condition that 
can only be considered as pathological, and all the more 
so, since all the petrous bones examined were not found in 



INFANTILE AURAL CATARRH. 395 

this condition, but one-fourth, or thirteen out of forty- 
six examined, contained no pus or hyperaemic membrane. 
The experience of physicians, however, has not shown 
that purulent inflammations of the ear appear as often in 
young children as would be thus indicated. May it be 
true that such an otitis interna as our examinations have 
shown, is only an anatomical or normal condition, and 
that it never evinces itself by any disturbing symptoms 
during life? 

As I have already said, I am not able to give a positive 
answer to this question. Is it probable, however, that 
changes in structure similar to those which in adults give 
rise to evident symptoms, and which affect not only the 
part involved, but the whole organism, is it probable, I 
ask, that these changes produce no results, when occurring 
in children? In general we know that the nervous system 
and general condition of a child reacts even as strongly as 
that of an adult to any disturbing cause. As long as we 
have no positive evidence of such a change in the relative 
irritability of children and adults, may we not assume that a 
whole class of symptoms occurring in sick infants have been 
improperly estimated, or imperfectly observed, that is, that 
they have been overlooked? I have been obliged, in almost 
every section of aural surgery which we have studied to- 
gether, to show you more or less important facts, which have 
either not been considered sufficiently, that have been im- 
properly estimated, or those which have escaped the observ- 
ation of practitioners, and, for the greater part, of aural 

1 surgeons also. I will at this time only recall one instance to 
your mind. How far, hitherto, have physicians known that 
impairment of the intellectual powers, a heaviness of the 
head, and troublesome attacks of vertigo, have had anything 

fto do with a diseased condition of the ear, while the daily 
occurrence of such cases to the aural surgeon proves the 

! coexistence of these symptoms with aural disease ? Notwith- 



396 INFANTILE AURAL CATARRH. 

standing this, the most cultivated clinical physicians seem 
to have no idea of the signification of these symptoms, and 
you will not find in the writings of the older German aural 
surgeons anything to indicate that they may be observed. 

Nowhere dare we leave less to authority, nowhere can 
we rely so little on previous researches, and nowhere can 
considerate and assiduous observations of clinical and ana- 
tomical facts find so much that is new and unexpected, as 
in the pathology of aural surgery. The previous laborers 
have left much to be done. How insufficient and want- 
ing have been the observations hitherto made on the liv- 
ing, I have already shown you. I have been obliged, also, 
to show you that observations on the dead body in some 
directions are entirely wanting, while in others they are 
incomplete. 

If, for instance, in the examination of the infant 
cadaver, attention had been turned to the temporal bone, 
the striking appearances then seen would have certainly 
arrested the attention of the physician. 

Scbwartze has recently called attention to the fact that Du Verney, 
a Frenchman, had shown the condition of things that I have de- 
scribed as occurring on the infant cadaver, nearly two centuries ago. 
In his Jractatus de Organs Auditus, his words are : " Aperui etiam 
complurium infantium aures, in quibus tympanum excrementis erat ple- 
num, interim nunquam, neque in cerebro neque in osse petroso, inventd 
ulla prava dispositione." 

Henle's Hand-book of Anatomy (11 Bd., 1866, s. 737) also called 
attention to a dissertation given at Marburg, in 1857, by Koppen, 
"on a collection of fluid in the tympanic cavity of the newly born." 
Koppen found the cavity of the tympanum empty in three children 
only, while a fluid which could not, however, be described as pus, 
existed in eleven cases. 

The examination has been neglected; the facts have, 
consequently, not been shown, and even now it is only 
exceptionally that a physician who can give no point of 



INFANTILE AURAL CATARRH. 397 

origin for the pain, thinks of the ear, and of the possibil- 
ity of an inflammation there, until a purulent discharge 
shows itself. 

If we examine the literature of the subject more closely, 
we find that in various times, observing and careful men 
have plainly shown that perforation of the membrana tym- 
pani, and the otorrhoea following it, were merely the results 
of otitis interna, that this must always be more common 
than otorrhoea, and that should we attempt to recog- 
nize the affection at an earlier date, in order to guard 
against the purulent discharge, and cause the whole pro- 
cess to run a mild course. In 1825, Dr. Schwartz, a phy- 
sician in Fulda, said, that "inflammations of the ear occur- 
ring in children not old enough to speak, are very often 
overlooked," and he called attention to the symptoms 
by which they might be distinguished from other affec- 
tions, especially from inflammation of the brain and its 
membranes. 1 Frederich Lud. Meissner, in his Text-Book 
of the Diseases of Children, says, that "aural inflamma- 
tion is of that kind most commonly overlooked in child- 
hood, because infants are not able to indicate the situation, 
kind, and degree of the pain." 

It is most commonly confounded with diseases of the 
brain. According to Helfft (1847), "the symptoms of 
otitis interna in children are very similar to true meningitis. 4 
We must always look to the head as the point of origin 
of loud and intermittent cries of pain, when the chest and 
abdomen have been found in a normal condition. The 
absence of vomiting and constipation, as well as the slight 
febrile reaction, are proofs that there is no considerable 
inflammation in the brain." 

1 See Siebold's Journal fiir Geburtshilfe, B. 5, Hit. I. Again presented in the third part 
of Linkers Sammlung auserlesener Abhandlungen und Beobachtungen aus dem Gebiete der Ohren- 
heilkunde. 

2. Journal fur Kindtrkrankhciten^ Schmidt's Tear-Book. 1848. B. 58, p. 337. 



398 INFANTILE AURAL CATARRH. 

These various indications seem to have been little 
regarded; and since they were given we seem to have gone 
backward, for you will find no attention paid to the sub- 
ject in our present text books. In the well-known works 
of Rilliet and Barthez (1B53), and in that of Bouchut 
(1852), I can find nothing pertaining to the subject, and 
quite as little in other text-books on the diseases of child- 
ren, even in those which have appeared since 1858, in 
which year I made my first communication concerning this 
peculiar post mortem appearance in infants, to the medical 
society of this city. 

Hauner, 1 however, has recently said of otitis : "In very 
young children it is often difficult to recognize this affec- 
tion, because the symptoms are very similar to those from 
those of a cerebral disease — acute meningitis. It is only 
by a consideration of all the symptoms, and of the physi- 
ognomy of the child, that we may be able to determine 
the seat of the affection." 

As far as my knowledge extends, the only physician for 
children, who has as yet given this subject any special 
attention, is Professor Streckeisen, of Basle. We may 
expect 'that we shall yet receive still more detailed com- 
munications as to his observations in this direction. In 
his report of the Child's Hospital in Basle, on page 13, he 
says: "Five children died of meningitis and encephalitis. 
In four cases severe purulent catarrh of the cavity of the 
tympanum was found, which must be regarded as the 
point of origin of the disease. In one case the inflamma- 
tion of the brain existed in a pure form." Again: "In 
pneumonia occurring in infants who were brought up by 
the bottle, convulsive symptoms generally occurred in the 
last three days. The explanation of these was found, on a 
post mortem examination, to be a catarrh of the cavity of 
the tympanum, and incipient meningitis." 

i Beitrage zur Padratrik, Berlin, 1863. B. I, s. 227. 



INFANTILE AURAL CATARRH. 399 

I am somewhat in doubt whether the form of disease described by 
Rilliet and Barthez as " cerebral pneumonia," and by Ziemssen as 
" croupous pneumonia with cerebral symptoms," was not in the most 
cases an inflammation of the lungs, with purulent catarrh of the 
cavity of the tympanum. I confess I consider this very probable. 
We should never neglect to examine the cavity of the tympanum 
when such cases occur. It is not very difficult to do this. 

But, gentlemen, not only anatomical facts, but also 
daily practical experience, prove to us the uncommon 
frequency of diseases of the ear in children. Ear-aches 
are such common occurrences in children who are old 
enough to exhibit the seat of pain, that we scarcely know a 
child that has not suffered, at one time or another, with 
them. Examination shows that this ear-ache generally 
depends upon inflammation of the external or middle ear, 
and that it is seldom of a nervous or neuralgic nature. 
Of the otorrhoea that comes under our care, the greater 
part, certainly more than half, has its origin in childhood 
or infancy. Impairment of hearing, of different grades, 
will often be found in children when a test examination is 
made. 

If, then, it is a generally acknowledged experience that 
inflammatory diseases of the ear are quite common in 
older children, it is probable that they occur quite as often 
in the very first periods of childhood, and that we are not 
able to detect it, simply on account of the difficulty of 
recognizing an aural affection in infants, when there is no 
purulent discharge. 

The anatomy of the parts, and the history of their de- 
velopment, also prove how favorable circumstances are, in 
infancy, to disturbances of nutrition in the cavity of the 
tympanum. 

I may recall to your recollection that process of dura 
mater, so rich in vessels, which in childhood extends along 
the whole of the fissura petroso-squamosa, to the cavity of 



400 INFANTILE AURAL CATARRH. 

the tympanum and the mastoid cells, and through which the 
dura mater and the mucous membrane of the middle ear 
come into closer relations in respect to nutrition than is 
the case with adults. Each of the disturbances of nutri- 
tion and circulation in the membranes of the brain, such 
as are quite common to children, must extend to the mid- 
dle ear, from the fact that the blood supply" of both is 
conveyed in the same channel; and the reverse is also 
true — every primary affection of the ear in a child is apt 
to produce symptoms of cerebral disturbance. I must 
not omit to state that, in all the cases of infantile external 
otitis, where I was allowed to make a complete examina- 
tion, I found also congestion and hyperemia of the 
brain. 

I have still further to speak to you of the condition in 
which we find the cavity of the tympanum in the foetus 
and the newly born child. As I have shown, 1 it is filled 
up with a cushion-like swelling of the mucous membrane 
of the wall of the labyrinth, which reaches up to the 
smooth internal surface of the membrana tympani. The 
respiratory process soon diminishes this mucous prolifera- 
tion, partly by shrinkage and increased desquamation, and 
partly by degeneration of the structure, and causes it to 
give place to air. 

We know from daily experience, that in the first period 
of life a developing process, or better said, a recession 
process is going on in the middle ear. Our daily practi- 
cal experience teaches us that pathological changes, inflam- 
mations, and new formations interfering with the nutritive 
processes, are more easily produced in parts which are in- 
creasing in power, and where metamorphosis and evolu- 
tions are going on. As an example of the truth of this, 
you will remember how often diseases of the female sex- 
ual system originate during the time of development, 

i Wiirzburg Verhandlungen. B. 9, case 78. 



INFANTILE AURAL CATARRH. 40I 

during each menstrual period, and especially during the 
puerperal process. 

If we add to these facts, that nasal and pharyngeal 
catarrh, which so often give origin to catarrh of the ear, 
are an every-day experience with children, you will be less 
surprised at the uncommon frequency of otitis in the 
young subject, and the only question will be whether we 
are able, with some certainty or probability, to recognize 
the affection during life. 

If the function of respiration be indeed of as great importance for 
the middle ear as Lucae's experiments show, all pathological processes 
in the organs of respiration, and particularly deficient respiration, 
such as is quite often seen in atelectasis of the lungs, must very 
readily lead, especially in children, to abnormal conditions in the 
cavity of the tympanum. It is even conceivable that a long-con- 
tinued death struggle (Agonie), under certain circumstances, may lead 
to the above described condition in the ears of small children. 

You comprehend, gentlemen, the difficulty of a diag- 
nosis of an affection of the ear, unaccompanied by a dis- 
charge, in young children who are not able to designate 
a situation for their pain, and when it is almost impos- 
sible to make any sufficient examination of the part, or to 
determine the degree of hearing. You see that we want 
nearly all the fixed points, such as in adults, enable us 
to distinguish an inflammatory affection of the ear. Yet, 
you must not allow this state of things to deter you from 
your duty. In internal diseases, especially in the practice 
among children, we are very often obliged to be content 
with very few positive conclusions, to diagnosticate by 
exclusion, or from greater or lesser probabilities, and also 
to look very much at the result of our therapeutics. We 
are not, strictly speaking, in a worse position for the for- 
mation of a diagnosis in these aural cases than in many 
others. The principal difficulty lies in the fact that: — 

5 1 



402 INFANTILE AURAL CATARRH. 

the physician who approaches the bed of the sick child 
scarcely counts non-suppurative inflammation of the ear 
as among the various possibilities which go to clear up 
the symptoms. If we but once understand that diseases 
of the ear belong to the more frequent ones of children, 
and compare the symptoms with which these affections 
declare themselves in grown persons, with those peculiar 
to the infant organism, we may certainly be able, by 
exclusion of the other organs, to make our circle narrower 
and narrower, until finally, with more and more certainty, 
we fix upon the ear as the origin of the trouble. Our 
conclusions will also be assisted by a previous experience. 

Allow me, then, to enter into a further detail of the 
symptoms by which otitis interna will show itself in young 
children. I must declare, however, that a diagnosis from 
analogy is only allowable because in the peculiar circum- 
stances clinical proofs of a definite pathological condition 
are wanting. Parents, who bring their children with 
otorrhcea to the physician, will often give considerable 
information as to the condition of the patient the day 
before the discharge began. 

When the collection of pus is at all considerable, the 
symptoms of irritation can scarcely be wanting, and the 
affection will declare itself by a morbid disquiet, and by 
the loud cry of severe pain. Some physicians ascribe a 
peculiar character to the cry of children in otitis; whether 
this be true or not, we may leave undecided. Certainly 
the cry which arises from pain in the ear, even when 
coming from strong men, may be described as one of the 
most agonizing, it being extremely severe and penetrating. 
This pain sometimes lasts for hours, often even for days, 
without very long intermissions, until hoarseness and com- 
plete exhaustion have ensued, and severe exacerbations 
often occur, especially during the night. 

The shrieking will distinguish it from affections of the 



INFANTILE AURAL CATARRH. 403 

lungs, pleura and trachea, since in these diseases children 
can never cry loudly or for any continued length of time. 
The cry from ear-ache most resembles that from inflam- 
mation of the bowels or brain, but the absence of the 
remaining symptoms of these diseases will enable us to 
distinguish trouble in the ear from these diseases. 

It will be important to note the circumstances under 
which the pain seems to be decreased or increased. In 
affections of the middle ear the pain is increased by every 
movement and shaking of the body, and every change in 
the position of the head, by every effort of swallowing, 
and in suckling the child will fling itself away from the 
breast, or from the bottle, at the first attempt, while its 
usual nourishment, administered by means of a spoon, 
will be more easily taken. If the affection be in one ear 
only, the child will cry more violently if placed upon 
the affected side. Cold and noise will increase the pain, 
while perfect quiet, warmth, especially moist warmth, such 
as pouring warm water into, the canal,* and the application 
of cataplasms over the ear, will quiet the pain. Nasal 
catarrh — cold in the head — will be a common com- 
plication. 

You will find it very difficult to come to any conclusion 
as to the degree of deafness, or loss of hearing, which is 
connected with the accumulation of purulent matter in the 
middle ear. It is true, that even in the most tender age 
we can come to an unequivocal determination as to whether 
the child hears a loud noise or not, but who can tell, in a 
disease connected with depression of the sensorium, 
whether a child does not respond to sounds, from want of 
power in his auditory apparatus to conduct the sound, or 
from want of power of the brain to perceive it? When 
we remember the facts, often alluded to, of the relation 
of the vessels of the dura mater and the mucous mem- 
brane of the middle ear, in the child, and the tendency of 



404 INFANTILE AURAL CATARRH. 

extension of diseases of the ear to the brain in the adult, 
we need not be surprised — considering the very impressible 
brain and spinal cord of the child — if the meningeal and 
cerebral symptoms are here much severer than in adults, 
and that stupefaction, or convulsions of the limbs, or 
spasms of the facial muscles, are produced by an otitis 
media. Nasal catarrh is one of the common symptoms. 
I must very earnestly urge upon you the employment of 
Politzer's method of inflating the drum in such cases. 
We should often force the air into the ear, and observe 
what effect it has upon the pain, disquiet, and crying of 
the little patient, and notice especially if it makes any 
impression upon the blunted or irritated condition of the 
sensorium. 

The fact may have occurred to you that, in the post 
mortem examinations, whose results are now under con- 
sideration, the membrana tympani was never found per- 
forated, and that it took very little part, comparatively, in 
the morbid process. This may be due to the width of the 
Eustachian tube in infancy. It is not only relatively, 
but absolutely wider than in adults, measuring, in its nar- 
rowest part, about a line and a half, or three mm. There- 
fore, a complete closure of the cavity of the tympanum, 
and a consequent collection of secretion in it, with the 
well-known results, is not so liable to occur. These 
anatomical conditions allow us to say, that in otitis there 
is much less danger to the membrana tympani of children 
than in that of adults, and that the prognosis is, on the 
whole, better in the former than in the latter. Perhaps the 
disease may run its course in the young subject without 
any decided pain. 

Treatment, — What shall be the therapeutics for an 
otitis interna thus in all probability diagnosticated, as 



INFANTILE AURAL CATARRH. 405 

occurring in an infant? In the case of a strong, well- 
developed child, we may apply one or two leeches behind 
the ear to relieve the pain and hyperemia. I would not 
generally apply poultices to the ear, since they will cer- 
tainly excite a profuse otorrhcea, and the frequent filling 
the ear with warm water will probably subdue the pain 
quite as effectually. 

Injections of cold or lukewarm water in the nose will 
have a good effect in removing mucus from the nasal cavi- 
ties and upper pharyngeal space, and they are especially to 
be recommended when there is a severe cold in the head, 
which is a frequent accompaniment of the otitis. They 
also serve to assist in the diagnosis. 

I would like to speak of a popular remedy for cold in 
the head, that often does good service in many forms of 
nasal catarrh occurring in children — that is, the insertion 
of an oiled and pointed pigeon's feather through the nose 
into the pharynx; this is to be done at somewhat frequent 
intervals. It excites sneezing, and assists materially in 
clearing out the parts. Since there is a very slight amount 
of danger to the membrana tympani, and the secretions of 
the cavity of the tympanum are easily removed, an emetic 
will be very useful in some cases. 

Politzer's method will be found particularly important, 
not only in the diagnosis, but also in the treatment of this 
purulent catarrh. By this method the tube is opened and 
the possibility of an exit is afforded to the pus that has 
collected in the upper part of the canal. We have already 
seen how easily the manipulations necessary in this pro- 
cedure are made in the case of children, where the simul- 
taneous swallowing is not essential to the success of the 
attempted inflation. 

I hope, gentlemen, that you will follow out this sub- 
ject in your future practice, and when you can ascribe no 
sufficient reason for the crying of a child, and for its stupid 



406 INFANTILE AURAL CATARRH. 

or convulsive condition, that you will remember the fre- 
quent recurrence of the pathological picture which we 
have seen in these sections, especially if the existence of a 
severe cold in the head indicates a catarrhal affection in 
the ear. 

There is a prevailing custom among many physicians, 
to ascribe many of the troubles of the first period of life 
to the cutting of the teeth. We can not deny that this 
view has historic right, as well as the vox populi, on its 
side, and that it is extremely convenient. It does not ap- 
pear to me, as proven, however, that a physiological pro- 
cess for which preparations have been made, and which 
goes on with so few local and sudden changes, should 
constantly lead to constitutional disturbances of the 
system. 

According to Kolliker, the development of the twenty milk teeth 
begins as early as the sixth week of foetal life, and in the seventh 
foetal month their ossification has begun. In the remaining teeth the 
first stages of development begin at the fifth month of intra uterine 
life, and ossification begins before birth. 

Let it be as it may, I do not intend to express myself 
very decidedly on the vexed question. This much is 
certain, that abominable malpractice is often seen in diffi- 
cult dentition ; exact examination is often omitted, for the 
above-mentioned convenient subterfuge, while many very 
important local disturbances are overlooked. Among the 
last, may we not place the variety of otitis, which has just 
been described. 

I am in possession of but one complete history of a case of an older 
child, where the above described pathological conditions were found,, 
for which I am indebted to the kindness of my honored friend, Pro- 
fessor Streckeisen^ in Basle. (I take the liberty of somewhat con- 









CASE OF INFANTILE OTITIS. 407 

densing the case, which Dr. Troltsch gives in full on page 308 of 
the original of this work. St. J. R.) 

A well-developed, healthy child, six years of age, after returning 
from a walk, was seized with headache, heaviness, and bilious vom- 
iting. After a restless night, on the following day the symptoms dis- 
appeared. On the evening of the second day, the same symptoms 
return, surface heated, pulse 130 — all the appearances of congestion 
of the brain. Treatment, leeches between lower jaw and mastoid 
process, cold application to the head, cathartic. Symptoms disappear 
and do not return for three or four days. 

Fifth day. All the symptoms of cerebral congestion reappear — 
restlessness, disposition to weeping, anxious visage, head hot, slow 
drawing back of the tongue, etc. Blood was taken from the Schnei- 
derian membrane, cold applications to head, and cathartic of calomel. 
Symptoms again disappear. 

Sixth day. Gradual symptoms of cerebral pressure began to ap- 
pear, drowsiness, some difficulty in waking, remaining' till seventh 
day, when pouring cold water over the head seemed to have some- 
what revived the patient, though not fully. 

Eighth day. Paralytic symptoms appeared. 

Ninth day. Increased. 

Tenth day. In the morning she died. 

Sectio cadaveris showed serious infiltration and congestion of the 
brain, swelling of brain substance, and consequent pressure. Both 
lateral sinuses filled with coagula. Cavity of the tympanum, and 
mastoid cells, on both sides, filled with pus. Mucous membrane of 
the ear greatly injected and swollen. Membrana tympani slightly 
sunk inward. 

The following facts are especially remarkable in this case : 

I. The very slight prominence of the pain in the head on the first 
! and second days. On the reappearance of the affection on the fifth 

day, this symptom appeared, accompanied by sobbing and crying. 

II. Entire want of convulsive symptoms during the period of irri- 
tation, rapid progress of the cerebral pressure, and paralysis. 

III. Entire absence of pain referred to the ear. Although this 
point was not specially observed, still this much is certain, that the 

\ child did not complain of pain, and that it heard well on the sixth or 

seventh day of the duration of the disease, for during the intervals 

i of consciousness it gave correct answers to its brothers and sisters. 



408 dr. wreden's cases of infantile otitis. 

It is much to be desired that physicians who see much 
of infantile diseases, would interest themselves in this 
matter of the occurrence of otitis, and thus bring us to 
some exact conclusions. I would myself be very thank- 
ful for any communications on the subject. 

(The translator would be very thankful for any oppor- 
tunities to examine, post mortem, the auditory apparatus 
of young children. 

While these pages were passing through the press, Dr. Robert 
Wreden, 1 of St. Petersburg, published an article which throws very 
considerable light upon this subject of aural inflammation in the 
newly born. I regret that the article is as yet incomplete, and 
that consequently the full conclusions can not be given. They are 
here presented as far as they have been published. 

Dr. Wreden has examined the auditory apparatus of eighty infants. 
They were all foundlings. The youngest was twelve hours old, the 
oldest, one year and two months. The greater number were only 
from three to fourteen days old. There were no very marked 
pathological changes in fourteen ears, or seventeen and one-half 
per cent. All the infants whose ears exhibited disease to any con- 
siderable extent, died of severe affections ; thirty-six of pneumonia, 
sixteen of atelectasis congestiva, eleven of hyperemia meningum, eight 
of cedema meningum, three of meningitis suppurativa, and so on. It 
is thus seen that they died of affections which must necessarily in- 
volve the auditory apparatus, in view of the intimate anatomical rela- 
tion existing between both the cerebral cavity and respiratory organs 
to the mucous membrane of the middle ear. In only one case was 
the ear primarily affected. It then led to a fatal constitutional dis- 
ease. Of the fourteen ears in which the pathological changes in the 
ears were slight, five were in a perfectly normal condition. In the 
nine remaining there was a slight venous hyperaemia of the mucous 
membrane of the middle ear, which was probably a post mortem 
change. 

The following conclusions were reached by Dr. Wreden from an 
examination and study of the cases above cited : 

I. None of the children who had normal ears died of pneumonia 

i Monatsschrift fur Ohrenheilkunde, July, 1868. 






DR. WREDEN S CASES. 409 

or meningitis. This was shown, of course, by a post mortem exa- 
mination of the brain and lungs. 

2. Those cases in which there was a slight amount of hyperaemia, 
were those in which there was but very little congestion of the lungs 
or brain. 

3. The mucous cushion, discovered by Troltsch (vide page 406 of 
this work), which fills the cavity of the tympanum of the foetus, is 
completely absorbed in the first twenty-four hours after birth. This 
is proved by two cases of children a day old, where the cavity of the 
tympanum was perfectly free, having a smooth and normal mucous 
membrane. The body of an infant twelve hours old, showed that 
this cushion of mucous tissue was not absorbed in that time. The 
process of absorption was, however, going on, so that the tissue ex- 
isted only on the roof of the cavity, in the mastoid cells, and on the 
labyrinth wall. The respiration, crying, and suckling of the infant, 
are the actions which promote the absorption of this tissue. The 
cavity of the tympanum in children who were born dead, was com- 
pletely filled by this mucous cushion. This is an important fact for 
medical jurisprudence. Troltsch's idea that this tissue underwent a 
peculiar degeneration, and thus occasioned suppurative formation in 
the cavity of the tympanum, can not be sustained, but, knowing that 
complete absorption of this mass, should occur in twenty-four hours 
after birth, we may consider Troltsch perfectly justified in asserting 
that every formation of pus in the ear of the newly born, must be 
regarded as a pathological condition. 

4. Of the eighty children, thirteen, or sixteen and one-fourth per 
cent were affected with otitis media acuta, or acute catarrh of the 
middle ear. 

5. Simple or mucous catarrh of the middle ear was found seventeen 
times in the eighty children. This affection was never accompanied 
by consecutive inflammation of the brain and its membranes. 

6. Purulent inflammation is among the most important and fre- 
quent diseases of the infantile auditory apparatus. It occurred thirty- 
six times in the cases under consideration. More than half the cases 
of suppurative inflammation of the middle ear were accompanied by 
consecutive affections, which were often the direct cause of death. 

7. The membrana tympani was found to be perforated in but one 
case. This is a peculiar fact, that should be well-considered in the 
diagnosis and prognosis of otitis media purulenta neonatorum. 

52 



41 DR. WREDEN S CASES. 

Dr. WrederCs interesting article concludes with a reference to the 
importance of the function of respiration for the integrity of the ear, 
and refers to the investigations of Lucae, Schwartze, Politzer, and 
Troltsch, on the movements of the drum synchronously with the re- 
spiration, which have been already quoted from in this work. Lucae 
says : "It is not improbable that all affections which impair the 
respiratory act, also more or less directly impair the respiratory move- 
ment of the membrana tympani, and thus may lead to certain aural 
affections. " The observations of Rudinger and Mayer show that 
there is a constant communication through the Eustachian tube with 
the outer air, and are also evidence that affections of the respiratory 
organs may easily extend to the ear. 

In adults, also, the ear may be consecutively affected, when dis- 
eases of the lungs exist. In the last stages of phthisis pulmonalis^ 
impairment of hearing and tinnitus aurium, consequent upon consecu- 
tive aural catarrh, often occur. In cases of pneumonia, oedema, 
laryngeal croup, etc., no examinations of the middle ear have as yet 
been reported. St. J. R.) 



LECTURE XXIV. 

CHRONIC PURULENT AURAL CATARRH, OR CHRONIC OTITIS 

MEDIA. 

Objective and subjective symptoms; treatment; perforation of 
the membrana tympani; its importance, and the frequency 
with which it heals. 

THE ARTIFICIAL MEMBRANA TYMPANI. 

Historical; the various kinds; principle on which it acts. 

Gentlemen: We may now turn to the consideration 
of the chronic variety of purulent aural catarrh. This 
form is much more common than the acute. It is either 
developed from the latter, or it arises from the extension 
of an otitis externa, or an inflammation of the membrana 
tympani to the cavity of the tympanum. Not very 
unfrequently, however, suppurative catarrh of the ear 
appears primarily in a chronic form, that is, without any 
preceding acute inflammation, and has a very slow course 
from its very beginning. 

We can hardly conceive of a long-continued suppura- 
tive inflammation of the middle ear, without the occur- 
rence of perforation or destruction of the membrana 
tympani. In case it is not impaired, the membrane must 
have been greatly thickened by some previous affection. 
The pus from the deeper parts of the ear will naturally run 
outward. We may call this form of discharge otorrhoea 
interna, in contradistinction to otorrhoea externa, in which 



412 CHRONIC PURULENT CATARRH. 

affection the membrana tympani may remain intact for a 
long time. 

In the greater number of cases, the beginning of chronic 
otitis interna may be traced back to early childhood. The 
symptoms are mostly limited to impairment of hearing, 
and a purulent discharge from the ear, both of various 
grades and intensity. Pain is only felt after some distinct 
causes have been at work — such as an injury to the part 
during an ulcerative process, or during the sub-acute stages, 
or when an ulcerative or carious action is taking place. In 
the last named case the pain is very severe and long 
continued. 

If we syringe the ear we observe two kinds of secre- 
tion. The purulent, which is equally mingled with the 
water injected, and colors it yellow; and a mucous secre- 
tion which is not dissolved in the water, and which floats 
around the vessel in long and irregular grey flocculi. 
Sometimes there is more pus than mucus, and again more 
mucus than pus. There will also be little lumps, which 
consist of the dried secretion or epidermis from the canal 
and membrana tympani. 

On examination the lower part of the auditory canal is 
superficially softened and relaxed. The osseous part of 
the canal is often narrowed, and above and laterally it is 
covered by discolored crusts, consisting of dried and thick- 
ened secretion, or the lamellae of epidermis. These are 
often so large as to prevent a view of the background, and 
their removal alone may considerably improve the hearing. 
When the parts are greatly swollen, or the perforation is 
very small, it is often difficult to tell, even when the ear 
has been cleansed by a syringe, or a camel's hair pencil, 
whether there is any abnormal communication between the 
outer and middle ear or not. 

The presence of mucous flocculi in the water that has 
been syringed into the ear, indicates that the secretion is 



PULSATION ON MEMBRANA TYMPANI. 413 

from the middle ear. Air bubbles also lead us to suspect 
a perforation; a pulsating movement of a drop of fluid in 
the depth of the ear, is not seen, at least as a rule, unless 
the membrana tympani be perforated. 

Pulsating movements also occur, but very rarely, on a membrana 
tympani that is not perforated. 1 Politzer has also observed them on 
the swelled mucous membrane of the promontory. 

(I have the record of a case of acute aural catarrh, where the pulsa- 
tion was distinctly seen in the upper and posterior segment of the 
drum, by myself, and my friend, Dr. Rider, who happened to be in 
my consulting room when the case was presented. The drum 
remained intact throughout the course of the disease. St. J. R.) 

The perforation is seen most distinctly if the patient 
blows his nose or presses air through the tube. If the 
latter be permeable, the perforation small, and the secre- 
tion not too slight in amount, a whistling sound will 
occur, and at the same time secretion is not unfrequently 
forced into the auditory canal. 

On the other hand, there may seem to be a perforation 
when there is really none. A portion of the membrana 
tympani that is red and sunken may be easily mistaken for 
mucous membrane of the cavity of the tympanum. The 
edges of the depressed portion, if sharply defined, re- 
semble the edges of a perforation very much, especially 
since the latter are often partially adherent to the pro- 
montory. 

Lateral illumination, turning the mirror in such a manner 
that we may see under the edge of the perforation, or throw 
a shadow upon it, but especially an examination after an 
air douche or bath in such cases, will assist us to form a 
correct diagnosis. 

The membrana tympani, or as much of it as remains, 
is thickened throughout all its layers, not unfrequently 

1 Schwartze, A. F. O., I, s. 140. 



414 PULSATIONS OF MEMBRANA TYMPANI. 

it is partially calcified, and superficially covered by secre- 
tion, or at least infiltrated and dull in appearance. 

According to Politzer these calcareous degenerations, or deposi- 
tions, are to be considered, in the majority of cases, as the result of 
an otorrhoea that has run its course, where the exudation passing into 
the fibrous layer, from the adjacent ones, has undergone chalky de- 
generation. Even where the history of the patient does not speak 
of a discharge from the ear, we may often believe that one has ex- 
isted, because very many can not remember an otitis that occurred in 
infancy. 

The curvature of the membrana tympani is very often 
changed, so that individual parts are pushed backward 
and are adherent to the cavity of the tympanum. The 
borders of the perforation are usually reddened, of a 
roundish and distinct contour, and when they involve the 
center of the membrane, somewhat resemble a kidney with 
the hilus toward the handle of the malleus. 

The handle of the malleus, at its lower extremity, is 
sometimes exposed and lies in the middle of the perfora- 
tion. If the membrana tympani be for the greater part 
wanting, then only the uppermost portion of the handle 
of the malleus is to be seen. This, with the processus 
brevis mallei, as well as the outer border of the membrana 
tympani, almost always, remains, although it is often 
hard to recognize and distinguish it from the neighboring 
swollen tissue. In all the cases where the structure of the 
membrana tympani is perforated about the most concave 
portion of its concavity (or Umbo), the lower portion of 
the handle of the malleus, which is now deprived of its 
attachments to the membrane, lies deeper in the cavity of 
the tympanum. 

In some cases there is very little swelling or hyperemia 
of the exposed mucous membrane of the cavity of the 
tympanum, while in others there is a great deal. It is 



PERFORATIONS OF MEMBRANA TYMPANI. 415 

generally covered with secretion at the lower part, which 
may be pushed outward through the Eustachian tube 
with a slight whistling sound. In cases where the 
whole cavity is filled with pus, and the hole in the 
membrana tympani is a small one, the patient can press 
the secretion through the perforation drop by drop, 
without the slightest sound. At the moment when the 
patient stops the pressure, the drop, which was at the 
time passing through the perforation, will fall back into 
the cavity of the tympanum. Occasionally the edge of 
the perforation, even when it contains no drop of fluid, 
pulsates with the motion of the heart. This is always 
the case when there is any pus or fluid on the inner sur- 
face of the perforation; and then the pulsation is doubly 
distinct, on account of the strong and glancing reflection 
of the drop. 

Losses of substance occur in all parts of the membrana 
tympani, but most frequently anteriorly and below. They 
also occur in all possible dimensions. Very small ones, 
that only allow a small amount of light to pass through, 
appear black, almost like a spot of pigment on the mem- 
brana tympani. In larger ones the color depends upon 
the condition of the mucous membrane of the cavity, and 
the distance of the edges of the perforation from the points 
lying beneath. It is rare to see two perforations in one 
membrana tympani, but they do occur. Sometimes there 
is only a small bridge between the two, while again they 
are on very different parts of the drum. I once saw three 
different perforations on one drum. It was the case of a 
young patient with tuberculosis. 

Such perforations occur by far the most frequently in 
the intermediate zone, so that the center, as well as the 
> border of the membrane, still remain. Losses of sub- 
stance close to the annulus tympanicus are extremely rare. 
In one case I saw a peripheral detachment of the whole 



41 6 PERFORATIONS OF MEMBRANA TYMPANI. 

posterior half of the membrana tympani, by the formation 
of one extremely peripheral perforation below another. 
The bridge between them deliquesced, and thus the two 
were united. Another loss of substance suddenly ap- 
peared under this longish perforation, which enlarged in an 
upward direction, and then ran into the other. This was 
repeated several times, until within a short period the 
entire posterior half of the periphery of the membrana 
tympani was destroyed by suppuration, without any pain 
or other symptoms of irritation. 

As a consequence of this deficiency in the membrana 
tympani, that part of the wall of the labyrinth — the 
promontory — lying opposite the lower and anterior por- 
tion of the membrana tympani is exposed, and even when 
the mucous membrane of other parts is not swelled, ves- 
sels may be traced running over it. We may often, also, 
distinguish the anterior edge of the entrance to the fenes- 
tra rotunda. The membrane of the fenestra, in conse- 
quence of the oblique position of the niche on whose 
border it is first attached, can not be distinguished, even 
if the whole of the membrana tympani be gone. If the 
perforation be in the posterior or upper part of the mem- 
brane, or if the greater part of it is destroyed, the long 
process of the incus is frequently wanting. If it be 
wanting, the connection between the stapes and the other 
bones composing the chain is of course broken. We 
are occasionally, also, able to distinguish the little head 
of the stapes — generally situated on the most posterior 
and upper edge of the visible wall of the labyrinth — 
as a little elevation covered with reddened mucous mem- 
brane. Finally, a more common condition, both on the 
living and dead subject, is a union of the edges of the 
perforation with the ossicula auditus, or with the promon- 
tory. 1 According to post mortem examinations the handle 

Vide Virchow's Archiv., B. 21, 3d Hft. 



PERFORATIONS OF MEMBRANA TYMPANI. 417 

of the malleus is sometimes so much drawn inward by- 
direct adhesion of its end with the promontory, and lies 
so nearly horizontally that it cannot be traced from with- 
out, and thus the observer is led to believe that the whole 
lower part is destroyed by ulceration. 

The degree of hearing remaining in the above described 
conditions is very different in individual cases, reaching 
from total deafness to the ability to hear enough for the 
ordinary vocations. It depends greatly upon the amount 
of secretion and swelling. It is well known to you that a 
perforation of the membrana tympani by no means neces- 
sitates or involves a high degree of impairment of hear- 
ing, although you will often find an opposite view taken, 
not only among the laity, but also in the profession. 
Commonly, the hearing is so much affected in consequence 
of the perforation of the membrana tympani, that a watch 
which may be heard for six feet by a normal ear, can only 
be heard from one to two; but this leaves sufficient hear- 
ing for ordinary purposes. I know several persons with 
perforation of the membrana tympani on both sides, who 
are so little disturbed by it that they are not considered 
as deaf persons, or as even hard of hearing. Even a com- 
plete loss of the membrana tympani does not entirely 
destroy the hearing, although it must suffer severely there- 
from. 

It is not the hole in the membrana tympani that causes 
the most trouble to the hearing power, but the conse- 
quences of the inflammation which first caused the per- 
foration. The most injurious of these consequences is 
the thickening of the mucous membrane of the ossicula, 
and of the fenestras of the labyrinth. This may result 
from suppurative as well as from catarrhal inflammation. 
If a great amount of secretion still exist, the amount of 
hearing will depend to a great extent on the amount of 
secretion that has been collected on the parts that conduct 

S3 



41 8 PERFORATIONS OF MEMBRANA TYMPANI. 

the sound. Hence, in such cases the hearing varies 
exceedingly at different times. In the case of a small 
perforation the amount of thickening of the membrana 
tympani also comes into consideration. The patients, 
therefore, hear better, as a rule, when the perforations are 
of medium size, than when they are very small, because 
in the former case the sonorous waves, avoiding the mem- 
brana tympani, malleus and incus, pass through the per- 
foration directly upon the base of the stapes, and may 
thus reach the labyrinth to quite an extent. (Politzer.) 

Each perforation of the membrana tympani must be re- 
garded as of moment, and it has the following importance: 
the mucous membrane of the cavity of the tympanum 
thus loses its natural protection, and is open to atmo- 
spheric influences, and will be retained in an irritated con- 
dition, which may increase to an acute affection of more 
importance. Again, the existence of a perforation is 
generally the reason that a chronic otitis, with otorrhcea, 
often remains through the whole life of the patient, and 
can never be permanently healed. 

Such forms of disease often run on for years without 
any further consequence than that the patient has a dis- 
charge from the ear, and is somewhat hard of hearing. 
This condition does not receive the amount of attention 
which it demands, especially if it be on only one side. 
The discharge varies at different times in degree and kind, 
and sometimes disappears altogether for a time. The 
surgeon is generally first called to see such a case when, 
after a cold or injury, an acute and painful condition is 
present. If we except those cases where important com- 
plications, such as ulceration of the bones, have occurred, 
the pain and other symptoms in such a sub-acute otitis 
interna are less than in a primary otitis; because, in con- 
sequence of the perforation in the membrana tympani, 
there is seldom any great amount of secretion in the cavity 



PERFORATIONS OF MEMBRANA TYMPANI. 419 

of the tympanum, it being able to pass out, unless the 
opening is accidentally closed by a mass of epidermis or a 
thick scab. 

If neglected and left to itself, chronic otitis interna may 
lead to the formation of polypi, to caries, and to various 
disturbances, of whose great importance for the life of the 
patient we shall speak more fully. We are often able, by 
proper and long-continued treatment, to bring such a pro- 
cess to a stand-still — to lessen the purulent discharge and 
hyperaemic swelling of the part; and we often, also, obtain 
with this a considerable improvement in the hearing. 

Under favorable circumstances we are often able to com- 
pletely cure recent affections, and sometimes even long- 
existing purulent catarrh of the middle ear, and to close 
the opening in the membrana tympani. To those who 
doubt that perforations of the membrana tympani will 
heal, I would like to adduce cases in my own experience, 
among which are those of two members of our profession. 
Some cases occurred to me where I was obliged to refer 
back to the history in order to see in what part of 
the membrane there was previously a perforation; so 
little trace of it remained. Where, however, the loss of 
substance was large, the cicatrix, or, more properly, the 
regenerated portion, can be distinctly seen, especially 
some time after the perforation has healed. I once exa- 
mined such a healed perforation on the dead body. 1 In 
this case the microscope showed that there had been a loss 
of substance, and that a spot a little thinner than the 
remaining portion of the membrane was a cicatrix. In 
practice we may quite often see such cases on the living. 
The cicatrices are generally seen as thin, sharp-bordered, 
slightly depressed spots, which sometimes have a peculiar, 
diffuse, mother-of-pearl-like reflection, and which, on 
blowing in upon the membrana tympani, stretch out in 

1 See Virchow's Archive, B. 17, p. 16. 



420 PERFORATIONS OF MEMBRANA TYMPANI. 

their full dimensions. Politzer has also shown that simi- 
lar thinned spots may result from a partial atrophy of the 
membrana tympani in the course of chronic catarrh of the 
cavity, without perforation of the membrana tympani. 

If a perforation should close, the patient will probably 
not hear so well immediately after; but we must not attempt 
to prevent the closure. If we open a freshly-healed per- 
foration, the patient will hear better for the 'moment, but, 
on the other hand, if we leave the cicatrix alone until it 
becomes firm, the hearing will either gradually improve of 
itself, or from the introduction of warm air, or the injec- 
tion of irritating fluids, just as in the treatment of chronic 
catarrh. This must not be attempted for some time after 
the perforation has healed, and then must be done with the 
greatest care, lest an otorrhoea be excited. The closure of 
the perforated membrana is the most desirable and perma- 
nent means of improvement, and our treatment should 
be directed to securing this end. We must avoid, how- 
ever, lessening the size of the opening until we have bet- 
tered the condition of the cavity of the tympanum, and 
the mucous surface of the membrane, or we shall not have 
improved the state of things, but, on the contrary, have 
made it worse, because, by so doing, we have rendered 
the exit of the pus, as well as the entrance of the fluid 
for cleansing the ear, and that used as an astringent, more 
difficult. We must always remember that we are dealing 
with a fistulous opening, which will heal with very little 
aid so soon as the morbid condition of the fistulous canal 
is removed; but that we shall render the condition of 
things worse if we close the opening without healing the 
canal, because the accumulation of a mass of pus, with all 
its consequences, is thereby favored. 

These cases were formerly described as "chronic inflam- 
mation of the membrana tympani, with perforation." A 
signification much too important and independent, was 



PERFORATIONS OF MEMBRANA TYMPANI. 421 

thus ascribed to the condition of the membrana tympani, 
and the real starting point of the whole morbid process, 
suppurative inflammation of the middle ear was overlooked. 
In consonance with this nomenclature, attempts were made 
to heal the perforation by direct irritation of its edges, a 
method which could only be appropriate after a purulent 
inflammation had run its course. {Gruber advises a num- 
ber of slight vertical incisions on the edges of the perfora- 
tion in such cases. 1 ) 

If we accept the view, however, that the persistence of 
a hole in the membrana tympani is a condition consequent 
upon a suppurative inflammation of the cavity of the 
tympanum, we should first of all attempt to cure the lat- 
ter. We shall subsequently learn, in the detailed state- 
ment that I propose to make on otorrhcea, that we may 
thus secure a closure of the perforation, without having 
directly localized our treatment upon it. 

An exception to this rule is formed by those cases where 
the perforation is maintained by partial adhesion of its 
edges to a portion of the cavity of the tympanum. Un- 
der such circumstances the healing of the perforation is 
sometimes secured by a mechanical separation of such 
adhesions, either by an operation, or by pressure from 
within, by means of the air douche, or by frequent 
exhaustion of the air by means of a gutta-percha tube 
passed into the auditory canal, or by the use of Siegles 
pneumatic aural speculum. (See figure on page 286.) 

The Artificial Membrana Tympani. 

Historical. — In order to neutralize the evils produced 
both upon the hearing and the cavity of the tympanum, 
by a great loss of substance in the membrana tympani, 
attempts were made more than two hundred years ago to 

1 Bericht, 1866, S. 6. 



422 ARTIFICIAL MEMBRANA TYMPANI. 

construct an artificial membrana tympani by which the 
opening might be closed, and the portion that is wanting 
replaced. 

Marcus Banzer 1 (1640), recommended for this purpose a tube of 
elk's claw, the end of which was covered by a piece of a pig's blad- 
der. Leschevin, in 1 763, also had an idea of an artificial membrana 
tympani. Autenreith, in 1815,* proposed to make an artificial drum 
from a short lead tube, with an elliptical opening, over whose inner 
extremity a bit of the swimming bladder of a small fish was placed, 
while wet, and varnished after drying. Linke* states that he has 
employed tubes most essentially in this manner, and with good result. 
He gives a sketch of the instrument. 

Toynbee, in 1853, proposed to use such an artificial 
membrana tympani, without, as it seems, knowing of the 
previous suggestions of a similar contrivance. It consists 
of a thin disk of vulcanized rubber, in the center of which 
a fine silver wire, a little more than an inch long, is 
attached, which terminates in a little ring by which the 
instrument can be readily removed. 

A mechanic in Nurenberg makes these instruments with an improve- 
ment on the method of attachment. The wire is inserted in the disk 

Fig. 34. 




Artificial membrana tympani. 

1 Disputatio de auditione laesa, Wittebergae, 1640, Thes. 104, 

2. Tubinger Blattern, B. I, St. a, s. 129. 

3 Hanbuch der Ohrenheilkunde, 1 845, B. II, s. 446. 



ARTIFICIAL MEMBRANA TYMPANI. , 423 

spirally, like a eork screw into a cork. It is thus rendered less liable 
to detach itself from the rubber and be left behind in the ear, an 
accident which quite often happened with Toynbee's instrument. 



Since this silver wire may very readily come in contact 
with the auditory canal, and cause, especially in eating, a 
very disturbing noise, August Lucae, of Berlin, uses 
instead of it, a little rubber tube of about an inch in 
length, and of two mm. in diameter, which is fastened to 
the disk of rubber by a solution of gum arabic. This 
latter instrument is introduced by means of a metal or 
wooden probe passed into the tube. 

Such an artificial membrane is pressed against the re- 
mains of the natural one, and sometimes causes a truly 
magical effect upon the hearing. I have seen cases where 
conversation could not be heard unless the voice were ele- 
vated in close proximity to the ear, so much improved 
that, some steps off, each softly spoken word could be 
repeated by the patient. In cases where the perforation 
is very small, and very much of the membrane remains, 
the artificial membrane often causes too much irritation. 
Its use cannot be continued for any considerable time 
when there is any evidence of recent inflammatory action, 
or any great amount of suppuration. 

Some patients only introduce it at times when they 
wish to hear particularly well. It must be considered a 
rule that the instrument, in the beginning, can only be 
worn for a short time, and that it is always to be taken 
out of the ear at night. 

Frequent cleansing of the ear, and the regular use of 
astringent ear drops, are the more necessary when this 
instrument is used, because the secretion will be increased 
by the presence of a foreign body. The cases are, how- 
ever, very frequent, where a long-continued use of such 
an apparatus is of no advantage, and where the patient is, 



424 



ARTIFICIAL MEMBRANA TYMPANI. 



on the whole, more benefited by the lessening of the sup- 
puration than by the use of such an instrument. 

We can never tell beforehand whether the instrument 
will do any good or not, and we must seek by repeated 
attempts to find the position where it improves the hear- 
ing the most. In what manner the benefit, which is often 
marked, from the use of the artificial membrana tympani 
occurs, we cannot exactly say as yet. It seems to me that 
there are various ways in which it may do good. 

According to Lucae, it improves the hearing because 
the fluid of the labyrinth is brought under a greater 
pressure. Besides, such a disk of rubber acts as a vibrat- 
ing plate, which may be able to carry a considerable num- 
ber of vibrations upon one of the ossicula. (Politzer.) 

Fig- 35- 




Sift 



Method of applying artificial drum. (Toynbee.) 



It is certainly seldom beneficial from the mere closure 
of the cavity of the tympanum, an explanation by which 



ARTIFICIAL MEMBRANA TYMPANI. 425 

Toynbee seeks to explain the improvement in the hearing 
attained by it. It often improves the hearing when its 
edges are so folded and everted that there is no perfect 
closure of the cavity, and even if a portion of it be cut 
off. In all cases the improved condition of the hearing is 
accompanied by the advantage that the mucous membrane 
is guarded from the effects of the atmosphere, and I often 
use the gutta percha for this purpose alone. In such a 
case the silver wire may be shorter, for it is not necessary 
that it should be introduced so far as to rest upon the 
remains of the membrana tympani. That the improve- 
ment in hearing by the use of Toynbee' s instrument did 
not depend on the closure of the cavity, I was able to 
prove in one case of a very small opening which I closed 
by the use of collodion, without benefit to the hearing. 
It was immediately improved, however, by the introduc- 
tion of the disk of gutta percha, or when any other firm 
body was pressed upon the remains of the drum. 

In the most cases it seems to be the pressure on the mem- 
brana tympani, and on the handle of the malleus, which 
causes this sudden and wonderful improvement. This 
opinion is sustained by the fact that the same effects which 
are obtained by the introduction of Toynbee's instrument 
are produced by the use of a little ball or wad of moist 
cotton, which is pressed on a certain part of the drum. 
Yearsley, of London, in 1848, first recommended this pro- 
cedure. The cotton wad is to be preferred to the gutta 
percha disk where the latter proves irritating, or when a 
considerable purulent discharge exists. 

(The use of this cotton drum was first suggested to 
Mr. Yearsley in 1841, 1 by a patient from New York, who 
had been in the habit of using a bit of paper moistened 
with saliva, with great benefit to his hearing. St. J. R.) 

By the use of an astringent with the cotton the sup- 

1 Yearsley on Deafness, p. 221. 

54 



426 ARTIFICIAL MEMBRANA TYMPANI. 

puration may often be diminished. Many patients are 
able to place the cotton on the right spot with the aid of 
a forceps, after a few attempts. In patients who are less 
intelligent, the disk of gutta percha is to be preferred, be- 
cause it is easier to introduce, and when it is misplaced it 
may be readily brought into a proper position. 

We can imagine various changes which would be likely 
to occur from the pressure of this foreign body on the 
membrana tympani and the handle of the malleus. 

We remember that in a purulent inflammatory process, 
especially, there is apt to be a solution of the continuity of 
the ossicula auditus. This occurs most commonly in the 
articulation of the incus and stapes, whether it be by sim- 
ple loosening of the soft capsule of the joint — a sort of 
luxation or disarticulation— or by means of a loss of the 
long process of the incus, which, as we have seen, is some- 
times destroyed by caries. When the membrana tym- 
pani, with the incus, is pressed against the stapes by a 
foreign body, the continuity will be restored. 

O. Erhard) of Berlin, author of the Rationelle Otiatrik 
(a queer book), claims to have been the first to discover 
the method of curing deafness by pressure on the mem- 
brana tympani in his own ear, and to have published it in 
1849, without knowing of the claims of Yearsley. 

These morbid changes, affecting the little bones of hear- 
ing, which would seem to be so seldom, are not as rare as 
we would naturally think. In Toynbee's catalogue of 
preparations of the ear, among the great number of sec- 
tions which he has made, the entire loss of the incus 
occurs four times. Its long process was wanting ten 
times, partially or fully, and in fifteen cases the articula- 
tion between the incus and stapes was lost. I myself found 
the last state of things three times on the dead body. In 
one case I was not able to get out the bones till eight days 
after death, and the separation which occurred may have 



ARTIFICIAL MEMBRANA TYMPANI. 427 

been only macerative, the cavity of the tympanum being 
filled with pus. The other cases can not be thus explained, 
for there was no injury done in opening the cavity. Such a 
separation of the very delicate connection between the in- 
cus and stapes may occur during life from a severe concus- 
sion of the head, and especially by means of a sudden 
change in the pressure of the air in the middle ear, just as 
a laceration of the membrana tympani may occur from the 
same cause. Recall to your mind what we observed in 
this respect in our observation of the physiological im- 
portance of the mastoid cells. Collections of puru- 
lent exudation may also produce such a result by ulcera- 
tion, and the whole chain of bones may :J suppurate and 
pass out. Further, a gradual or sudden bursting of the 
delicate membrane may occur by means of a strong expi- 
ratory effort, or of itself, when a spurious anchylosis, by 
means of adhesive bands, has rendered the parts inflexible. 
The last named condition obtained in my cases, and in a 
number of those of Toynbee. 

Politzer uses a bit of hard rubber from four to five lines 

■ 

long, and one and a half to two thick, fastened to a simple 
wire, for the purpose of an artificial drum, in practice 
among poor patients. In cases where the stapes is ab- 
sent, he fastens one taken from the cadaver to the artificial 
drum. 

As the separation between incus and stapes is by no 
means always a result of purulent deposits in the cavity of 
the tympanum and perforation of the membrani tympani, so 
the improvement in hearing by pressure on the membrana 
tympani may occur in persons where the membrane is 
entirely uninjured. I have seen one such case, where the 
introduction of a little wad of cotton improved the hearing 
for one day in a remarkable manner, and in the recent and 
ancient literature, you may find numbers of cases related, 
where patients, hard of hearing, have accidentally found, 



428 ARTIFICIAL MEMBRANA TYMPANI. 

that by the introduction of a foreign body in the ear they 
could temporarily hear better. As such assistances to the 
hearing, all possible things have been used — pencils, 
chewed paper, shavings, onion bulbs, lint, etc. One of the 
most interesting of these cases is related by Meniere, a dis- 
tinguished and excellent otologist. 1 

A deaf old judge had been accustomed for at least sixteen 
years, by pressure of a blunt gold needle against the mem- 
brana tympani, to produce for himself, for an hour or so, 
a tolerably good hearing-power. Meniere examined the 
ear during such a period. He found the membrana tympani 
uninjured, and that the pressure was made upon the handle 
of the malleus, which was pressed somewhat inward. He 
speaks of having seen several similar cases, and considers 
them cases of nervous deafness, which were improved to a 
certain degree by pressure upon the ossicula auditus, and 
through them on the labyrinth. 

(I have thought it proper to insert the notes of a few 
of the cases of the use of the artificial drum which have 
occurred in my practice, 2 with some remarks upon jhe 
requirements to be fulfilled in attempting to employ this 
instrument. 

Case I. A farmer, aged 30, from Michigan, fan., 1865. The 
patient had scarlet fever thirteen years ago, since which time he has 
suffered from periodical attacks of pain referred to the ears, discharge 
of pus from them, and vertigo. He has also been so deaf as not to 
hear ordinary conversation, ever since the attack of scarlatina. Pa- 
tient's general condition is bad, he having suffered much from inter- 
mittent fever. He cannot hear a watch at all, which should be heard 
by a person with normal hearing power, more than four feet, neither 
on auricle, mastoid process, nor frontal bone. The right membrana 
tympani has been wholly removed by ulceration ; no trace of ossicula 
auditus. Mucous membrane of the cavity of the tympanum hyper- 

* Traite des Maladies d'Oreille, par Kramer, traduit par Meniere. Paris, 1848, p. 526. 

* American Journal of the Medical Sciences, Vol. LI, p. 106. 



CASES OF USE OF ARTIFICIAL DRUM. 429 

trophied. A portion of the periphery is all that remains of the left 
membrana tympani. The incus and stapes remain in situ, but the 
malleus has been lost. Mucous membrane of the cavity of the 
tympanum also hypertrophied. Both Eustachian tubes are pervious, 
as proven by the Valsalvian experiment. The artificial membrana 
tympani was placed in the right ear without producing the slightest 
benefit ; being inserted in the left, it immediately so improved the 
hearing that the watch could be heard two inches from the auricle, 
and ordinary conversation several feet. The patient was enabled to 
pronounce isolated words after a speaker who stood more than twelve 
feet distant. The patient was under observation for a few days, 
during which time the hearing remained as good as above stated. He 
then left for his home, taking with him a supply of the artificial 
membranes. 

Case II. Miss U"., aged 30, New York. May 31, 1865. Pa- 
tient has been deaf ever since she can remember. Does not hear 
conversation unless specially addressed, and then the voice must be 
raised. She knows no cause for the deafness. Hears the watch two 
inches from the right auricle, not at all on the left side, except upon 
the mastoid process. Left membrana tympani opaque in its mucous 
and fibrous layers. The light spot is lessened in size, and the head 
of the malleus is abnormally prominent. Right membrana tympani 
perforated by ulceration in center, the remaining portion is granu- 
lated. A very slight amount of greenish fetid pus is secreted by the 
cavity of the tympanum and the remains of the drum. The 
pharynx is congested. Eustachian tubes impervious, as shown by 
the Valsalvian experiments, Politzer's method, and the catheter. 
General health not good, although no especial disease is recognized. 
Patient was seen every few days until August 5th, during which time 
the following treatment was carried on : Permeability of the Eus- 
tachian tubes was secured by the use of the catheter and Politzer's 
method, together with the use of gargles, and a weak solution of 
sulphate of zinc (gr. j., ad. aq. ^j.) was applied and worn, except at 
night. It caused at first much irritation and furuncular inflamma- 
tion. The artificial drum was removed until this was checked. 
The drum is now worn all day, and the watch is heard from six to 
eight inches with it, only two without it. Ordinary conversation 
heard fairly ; hearing on the other side as before. Patient expresses 
herself as being very much improved. 



430 CASES OF USE OF ARTIFICIAL DRUM. 

Case III. y. y. V, P., aged 28, Louisiana. Aug. 12, 1865. 
Three years ago, while in the artillery service, patient lost his hear- 
ing gradually, although he remembers, at one particular time, after 
being engaged in heavy firing, that he had a distinct sensation in the 
right ear, after which he was deaf from that ear for some time. The 
ears were treated, by the medical officer of the regiment, by the ap- 
plication of tannic acid. He continued in the service until the end 
of the war, and was subjected to various kinds of treatment, applica- 
tion of arg. nit., cup. sulph., and other astringents. At times he 
could hear quite well, and then his ears were " stopped up " for a 
time. He was exposed to much hardship during a great part of his 
term of service. The deafness has increased until now, when he 
can not hear at all from the right ear, and from the left with the aid 
of an ear trumpet. He does not hear the watch at all on either side. 
The right membrana tympani, except as to the upper portion, where 
a small rim remains, has been removed by ulceration. The integu- 
ment of the auditory canal, and the mucous membrane of the cavity 
of the tympanum, are hyperaemic and swollen. The little bones of 
hearing cannot be found. There is a slight amount of fetid pus 
secreted by the mucous membrane. On the left side the auditory 
canal is extremely hyperaemic, swollen, and tender. The epidermis 
is exfoliating. The membrana tympani is not seen, but the Valsal- 
vian experiment shows that it is perforated. Both Eustachian tubes 
are open. 

October 18. Since the first date the patient has been seen twice a 
week, and has been treated in the following manner : The ears have 
been gently syringed with warm water twice a day, a weak solution 
of the sulphate of zinc (gr. ss. ad. 3j.) has been dropped into the 
auditory canal and cavity of the tympanum, always warming it before 
use, and injections of the vapor of iodine have been made into the 
middle ear by means of Politzer's method for rendering the Eustachian 
tube pervious. The condition of the patient's ears is now as fol- 
lows : On the right side the hyperaemia and swelling are reduced to 
a minimum, as also on the left. In the left cavity of the tympanum 
the incus in position can now be distinctly defined. On this side the 
artificial drum is worn by day, except when the patient is alone for 
some hours, and removed at night. On the right side the drum has 
been worn at times, but never with any appreciable change as to the 
hearing power, which remains as when patient first came under observ- 
ation, except that he can now hear the alphabet pronounced through 



CASES OF USE OF ARTIFICIAL DRUM. 43 1 

an elastic tube. On the left side he can hear the watch over the 
auricle, and ordinary conversation near at hand with ease. He can 
hear a sermon in church, and goes once more into society, from 
which his previous amount of deafness completely excluded him. 
He does not use an ear trumpet at all, hearing better without the 
drum than he did formerly with the aid of a conductor of sounds. 
The patient is extremely intelligent, and to his strict attention to the 
directions given — his careful use of the artificial drum, removing it 
whenever it has caused the slightest irritation — a great part of the 
modicum of success attained is due. 

Case IV. Miss iV., aged 18. July 18, 1865. One year ago 
was quite ill ; the nature of the affection can not now be accurately 
ascertained. During the sickness both ears began to discharge pus, 
and deafness appeared. The discharge was checked, but the deaf- 
ness has gradually increased until now, when she can not hear ordinary 
conversation, and hears the watch only one inch from the auricle. 
Each membrana tympani has a central perforation, and there is a 
slight amount of yellow fetid pus secreted in the cavity of the tym- 
panum. The Eustachian tubes are pervious. The artificial drum 
improves the hearing on each side, by the watch, to a distance of six 
inches, and renders ordinary conversation easily heard. The patient 
was directed to daily syringe the ears with tepid water, using after- 
ward an astringent, and to wear the drum during the day. Patient 
has come to the office very irregularly, and carried out the, directions 
very inefficiently. She seems to have an aversion to the use of the 
the drums, wishes to be cured without wearing them. They cause 
considerable irritation of the auditory canal. 

Case V. Rachel C, aged 16. April 1, 1865. One year and a 
half ago patient discovered that she did not hear well. The deafness 
still continues, with some occasional pain and noise in the ears. She 
can hear the watch three inches from the right ear, one inch from 
the left. There is a perforation of each drum, with a slight ulcer- 
ative process going on in the membrane. Patient is of a strumous 
diathesis, has a curvature of the spine, but is just now in fair general 
health. Careful syringing of the ears, followed by the use of an 
astringe.it, was directed. There is no account of the condition of 
the Eustachian tubes until June 8, when Dr. C. E. Hackley inserted 



432 CASES OF USE OF ARTIFICIAL DRUM. 

an artificial membrana tympani, and made the following note : 
"Artificial drum tried, on the right side of which the Eustachian tube 
is pervious, the hearing distance increased to ten inches. Politzer's 
method of rendering pervious the tube was practiced. 

June 22. "Left Eustachian tube is now pervious, with artificial 
drum the hearing is increased to twelve inches." 

September 14. I saw the patient and made the following note: 
"Patient has been in the country, and has worn the artificial drum 
by day ever since. Hearing distance — right ear twenty inches, left 
two feet. Drums cause no irritation whatever." 

Two years after this patient continued to wear the drums with the 
same benefit. 

Remarks. — The cases above given have been taken without any 
particular choice, from a number of which I have notes, and which 
I occasionally see. It is the habit of the writer to tentatively apply 
the artificial membrane to all ancient perforations, where the hyper- 
emia and inflammation, or discharge of pus are not very considerable. 
Recent cases of perforation, as a rule, heal so readily that the use of 
the drum is not indicated. 

In order to a successful use of the artificial membrane — 

1. The Eustachian tube must be pervious ; 

2. The incus of the ossicula must be in situ ; 

3. The inflammatory action on the external auditory canal, and 
remains of the drum, must not be excessive. 

It is also of great assistance to the surgeon in procuring a success- 
' ful wearing of the artificial membrana, that the patient should be 
intelligent enough to realize that at the best the disk of rubber is 
a foreign body, which should be carefully removed at any approach 
of irritation. It is, therefore, not of much use in the case of children, 
or of unusually stupid or careless adults. It should also be stated 
that cases have been found, where all the above-named conditions 
have been fulfilled, where it was a priori supposed that the artificial 
membrane would do good, and yet repeated trials proved that the use 
of it effected nothing for the hearing. 

In these cases we may perhaps conclude that there existed very 
considerable rigidity of the quasi articulation of the stapes with the 
fenestra ovalis. St. J. R). 



LECTURE XXV. 

THE RELATIONS OF SUPPURATION IN THE EAR TO THE 

GENERAL SYSTEM. 

Caries of the petrous portion of the temporal bone and its con- 
sequences — cerebral abscess, purulent meningitis , paralysis 
of the facial nerve, destruction of the walls of the vessels; 
the influence of suppurative inflammations of the ear upon 
the vascular system — embolia, septic infection, metastases; 
tuberculosis and cholesteatoma of the petrous portion of the 
temporal bone. 

Gentlemen: Otorrhoea or purulent discharge from the 
ear is by no means an independent disease, it is only 
a symptom occurring in morbid processes that are essen- 
tially different from each other. It is therefore on practical 
grounds only, that we again consider the subject of 
otorrhoea in its relations to the whole organism, and with 
reference to its very common consequences. 

Otorrhoea occurs after acute and chronic otitis externa, 
myringitis and otitis interna, as well as from furuncles in 
the auditory canal, in other words both in external and 
internal aural affections. Aural polypi may also be con- 
sidered as sustaining causes of otorrhoea, although they 
are properly the results of inflammatory affections of the 
ear. 

Purulent discharge from the ear is a very common affec- 
tion, especially in children. This may be accounted for 

55 



434 PURULENT DISCHARGE FROM THE EAR. 

by the fact that it is developed in so many different 
diseases of the ear, and because it is generally left to itself, 
and therefore lasts a great while. 

Otorrhcea is generally considered of no particular im- 
portance, both by the laity and the profession, and thus it 
comes to be neglected. Sometimes it is even thought that 
the health would be injured by an attempt to check the 
discharge. 

In opposition to this general opinion, I have often, in 
the course of our meeting together, called your attention, 
not only to the importance of every discharge from the 
ear, for the affected organ, but also for the general condi- 
tion and life of the patient. In this last-named view we 
shall now consider otorrhcea, and the more minutely, since 
the importance attached to the subject, especially in Ger- 
many, is exactly the opposite from that which it requires. 
(This is also true of the United States.) 

Suppurative inflammation of the soft parts of the ex- 
ternal and middle ear, can not be regarded with indiffer- 
ence, because it may easily produce inflammatory softening 
of the bones, to caries, and because the anatomical rela- 
tions of these parts are very favorable to those morbid 
processes that lead to the well known embolic and septic 
diseases. 

Caries of the temporal bone very rarely depends upon 
a primary affection of the bone, but it is generally developed 
in the course of an otorrhcea that has existed for a long 
time, especially if it has been badly treated, or perhaps 
not treated at all. As we have already seen, the peri- 
osteum of the auditory canal, and of the cavity of the 
tympanum, are in the most intimate relation with the cutis 
or mucous membrane which lies over it. Hence severe 
disturbances of nutrition of the soft parts must almost 
necessarily lead to affections of the bone beneath. In 
every otitis externa and media, if the suppuration be not 



CARIES OF TEMPORAL BONE. 435 

gradually checked the bones must take more or less part 
in the inflammatory and ulcerative process. 

Carious affections, on whatever part of the body they 
may occur, as is well known, are generally considered by 
the profession, as very important, not only because they 
may excite great local destruction, but also because they 
may bring the life of the patient in the greatest danger, 
either from the blood poisoning or emboly which may 
result, or from the condition of debility or degeneration 
of internal organs to which they lead. 

Caries of the bones of the spine and cranium is par- 
ticularly dangerous. No bone of the cranium becomes 
carious so frequently as the temporal bone. In connection 
with the peculiar structure of this bone, there are some 
unfavorable conditions that come especially into consider- 
ation, and that cause its affections and with them the point 
of origin, suppurative inflammation of the soft parts, and 
otorrhcea, to appear in a very dark light, as far as a 
prognosis is concerned. 

I have already called your attention to the short dis- 
tance of the dura mater and the cerebrum from the upper 
wall of the external auditory canal, and also to the proximity 
of the transverse sinus, and of the mastoid cells, to the 
posterior wall. This proximity explains why these parts 
are sometimes involved in the inflammation, even when the 
caries is confined to the auditory canal. The anatomical 
relations are still more important in the cavity of the 
tympanum, since its lower wall, or floor, is frequently 
separated from the jugular vein only by a thin, translucent 
layer of bone. Again, the largest artery of the head, the 
internal carotid, with the venous sinus surrounding it, 
takes its course, on its anterior portion. These are 
separated from the cavity merely by a delicate and fre- 
quently defective bony lamella. Furthermore, its roof, or 
upper wall, which with the superior petrosal sinus lies 



43^ RELATIONS OF CAVITY OF TYMPANUM. 

between the mucous membrane and the dura mater, is not 
infrequently thinned and even perforated, and besides, 
even in adults, there is usually a gap in the bone — the 
petro-squaumosal fissure. 

The inner or labyrinth wall, finally, offers only slight 
resistance to the transition of the inflammation to the 
facial nerve, and through its two fenestra?, which are only 
closed by membrane, to the internal ear, and then to the 
meatus auditorius internus, which is covered by the 
membranes of the brain. Close under the mastoid pro- 
cess, which is intimately connected to the cavity of the 
tympanum, is the transverse sinus, which makes up the 
whole of these important relations. 

Now, I ask, gentlemen, if you know a small cavity 
in the human body, borders in a similar manner upon 
so many important organs, and in which we should, there- 
fore, so anxiously regard purulent processes and their 
common consequences? However, we do not speak here 
from a merely theoretical stand- point, but our practical 
experience shows us, and every surgeon knows, that caries 
of the bones of the ear very often excites affections that 
are dangerous to life. 

Inflammation of the brain substance, the formation of 
abscesses in it, and purulent meningitis, accompanied by 
changes in the structure of the upper wall of the cavity of 
the tympanum, have been observed to be the most common 
of the effects of caries of the temporal bone. According 
to Lebert, 1 who has called our attention to the frequent 
connection of abscesses of the brain with affections of the 
ear, about one-fourth of these abscesses have their origin 
in caries of the petrous portion of the temporal bone. 

If we look at the cases of abscesses in the brain, scat- 
tered here and there in the literature of aural surgery, we 
shall find that aural affections, in perhaps half of the cases, 

1 Virchow's Archiv. B. X. 



CEREBRAL ABSCESS. 437 

have been the cause of cerebral abscesses, and there is an 
urgent necessity in every such case to follow Leberfs ad- 
vice, and carefully examine as to disease of the ear. Asa 
rule, there will be found healthy brain substance between 
the external surface of the petrous bone and the purulent 
masses in the brain, and the dura mater on the tegmen 
tympani (a thin plate of bone forming the upper wall of 
the cavity of the tympanum) is considerably thickened. 
Much more rarely the deposits of pus run into each other, 
and thus have the appearance of being metastatic. 

This is not the place to go any further into the symp- 
toms of abscesses of the brain. I would only remind 
you of the great changes that may take place in the brain, 
unaccompanied by fever, and with no disturbance of the 
functions, especially of the intelligence. Severe local 
pain, increasing on pressure, is often for a long time the 
only symptom of an otherwise entirely latent affection of 
the brain, and death sometimes occurs very suddenly and 
unexpectedly with convulsive or apoplectic symptoms. 

(At the meeting of the New York Pathological Society, held 
January 23, i860, Dr. T. G. Thomas presented a specimen of 
abscess of the brain, resulting from otorrhoea, the history of which 
I condense somewhat and insert here) : " A girl about fourteen entered 
Bellevue Hospital on Monday, January 23 ; the general health had been 
good, except that she was subject to an occasional slight otorrhoea and 
convulsions, which were clearly of an hysterical nature, which had 
existed for a year. On the seventeenth of the present month, she 
was seized with a violent pain in the ear, which ceased on the twenty- 
first, and pus was discharged. 

" Headache complained of, and pain along the course of the spine ; 
vomiting and occasional delirium set in ; convulsions continued. 

" She died in a few days, and the diagnosis between profound 
hysteria and abscess of the brain was not established till the post 
mortem. 

" Abundant traces of pus were found at the base of the brain. At 
a point just above the petrous portion of the temporal bone there 



43^ CEREBRAL -ABSCESS. 



\ 






were fluctuations, and about one drachm of pus was evacuated. On 
incision, pus was found on the outer surface of the brain, which 
evidently resulted from local meningitis." 

"Dr. Bibbins referred to a case which he saw while on Randall's 
Island Hospital : A little child had otorrhoea with more or less hemi- 
plegia. The doctor noticed a suspicious purplish appearance behind 
the ear, which looked as if some portion of the mastoid process were 
about to exfoliate ; the child was doing well, not confined to bed, 
was suddenly seized with a convulsion and died. 

"Post mortem showed a large abscess of one lobe of the cere- 
bellum." 

My friend Dr. R. Hubbard, of Bridgeport, once told me that he had 
seen several cases within one week of practice. This is an example 
of their frequency. Almost every practitioner has seen such cases. 
Four have come under my personal observation, one of which is 
detailed elsewhere in this book.) 

Otitis and otorrhoea quite as often lead to purulent 
pachymeningitis ; and here the anatomical condition 
allowing the transfer of the affection, is commonly clearer 
and less doubtful, than is the case in cerebral abcesses. 
The inflammation of the cavity of the tympanum may 
extend in two ways upon the coverings of the brain, either 
through the tegmen tympani, that is, upwards, or, inwards, 
through the meatus auditorus internus. 

Inflammation of the roof of the cavity of the tympanum, 
and consequently of that part of the dura mater over it, is 
by far the most common result of suppuration and caries 
of the ear, as is shown by post mortem sections. This 
may depend, in good part, on the fact that this portion 
of the base of the skull and its changes, may be readily 
seen in an examination of the dead body, while many other 
morbid appearances must be carefully looked after by 
removal of the temporal bone. We may then question if 
they really occur most frequently in this situation, or 
whether they are only most often discovered. 

Some anatomical peculiarities of the roof of the cavity 



CEREBRAL ABSCESS. 439 

of the tympanum may explain the transition of inflamma- 
tion in this direction. 

I recall to your mind the fissure in the bone which exists 
here, and to the arterial branch, and the process of tissue 
which pass through this fissure from the dura mater to the 
mucous membrane of the middle ear, and by means of 
which, each nutritive disturbance in the cavity of the tym- 
panum and mastoid process will exert a certain effect on 
the dura mater. I may also remind you of the thinning, 
or rarefaction of the bone, which we have found to be quite 
common here, and which may thin the tegmen tympani 
even to perforation, without any declared caries of the 
bone. It is clear that in a case where there is very little, 
or, perhaps, no substance intervened between the mucous 
membrane and the dura mater, an extension of the inflam- 
mation may very easily occur, and that the gas evolved 
from such a purulent mass will be especially injurious to 
the tissue lying over it. 

The cases, where an otorrhcea, which has existed for years, 
has ended fatally, under the form of meningitis, while the 
roof of the cavity of the tympanum was not attacked, but 
the disease had extended from the internal auditory canal, 
occur very often in surgical literature. Very often, how- 
ever, an exact anatomical description of the intervening 
parts is wanting. In the cases which have been carefully 
examined, the inflammation and purulent discharge extended 
from the middle ear to the labyrinth, and thence upon the 
meatus auditorus internus. The wall of separation between 
the middle and internal ear — the labyrinth wall of the cavity 
of the tympanum, is thin of itself, and contains two fenestra^ 
vulnerable points, through which extension of morbid 
processes is very easy. Itard 1 speaks of such a case; and 
I can show you another where the delicate annular ligament 
about the base of the stapes was affected and thus the 

1 Traite des Maladies de l'Oreille. 2 Ed, 1842, Tome i, p. 210. 



44° CEREBRAL ABSCESS. 

purulent process found its way into the labyrinth. There 
are also many other preparations illustrating this point, 
especially those of Toynbee. If once the vestibulum 
and cochlea be affected, there is nothing between the 
inflammatory mass and the meninges, but a finely per- 
meated lamella of bone, through which the auditory nerve 
sends its soft, hair-like threads into the labyrinth, and 
thus, in the majority of cases, when the labyrinth is 
invaded, the process extends to the coverings of the 
brain. 

There is still, however, a third way in which a continu- 
ation of a purulent inflammatory process may be con- 
tinued to the cranial cavity. 

It is well known to you, that occasionally inflammations 
extend from one point to another along the course of a 
single large nerve twig, under the form of a peri-neuritis, 
an inflammation of the sheath of the nerve. A continu- 
ation of an inflammatory action may thus extend from 
the cavity of the tympanum, even when the integrity of 
the labyrinth is perfect, through the Fallopian canal along 
the facial nerve, and so much the more, since this nerve 
is very often involved in the affection. To my knowledge, 
no such connection between otorrhoea and meningitis has 
previously been observed. In a similar way the patho- 
logical condition may be transmitted along the connective 
tissue of the vessels and the nerves, to the most different 
parts of the ear. 

The anatomical considerations of the parts show us that 
the facialis must be often affected in otitis interna. Some- 
times the facial nerve runs for a considerable distance on 
the wall of the cavity of the tympanum, and is only sepa- 
rated from its mucous membrane by a thin, transparent 
lamella of bone. Sometimes, again, the stylo-mastoid 
artery, which supplies the greatest part of the membrane 
of the middle ear, takes its way through the Fallopian 



FACIAL PARALYSIS. 44 1 

canal, and gives off branches to the sheath of the facial 
nerve. 

Facial paralysis, of various grades, often following spasm 
of the muscles of the face, occurs not unfrequently in the 
course of an inflammation of the ear. Perhaps some cases 
of the so-called rheumatic facial paralysis, on more exact 
examination, will be found connected with affections of the 
cavity of the tympanum. Experience teaches us that the 
prognosis of this affection is not so unfavorable as it is often 
said to be, even in our best text-books of nervous diseases. 
Even very extensive facial paralysis disappears under treat- 
ment, if we are able to bring the process in the ear to a 
stand-still. I have seen quite a number of recent cases of 
one-sided facial paralysis fully cured by means of the sim- 
ple treatment employed in chronic otitis. (I may be 
permitted to confirm this observation by my own expe- 
rience. St. J. R.) 

Moreover, we see from the described anatomical condi- 
tions, that the appearance of paralysis of the facial nerve, 
in the course of an otitis, by no means involves danger to 
the life of the patient, for we cannot, therefore, conclude 
that the brain is taking part in the affection. Great inter- 
ference with the circulation and increase of secretion in the 
cavity of the tympanum, may be reflected upon this 
nerve. Caries itself, of the soft lamella of bone behind 
which the nerve runs, which will certainly excite facial 
paralysis, is by no means a very important matter, if it 
be not connected with more important changes. 

The symptoms of facial paralysis are well known to you. 
The first indication of its existence is, that the patient 
does not drink properly, and that the fluid escapes at the 
angle of the mouth, as in an awkward child; still more 
commonly the patient suddenly notices epiphora in one 
eye. This last-named symptom is almost always the first 

5 6 



442 ULCERATION OF AURAL BLOOD VESSELS. 

one complained of, and the carrying off of the tears, 
which, as you know, is accomplished by muscular action, 
is imperfectly accomplished even when the lids close ex- 
actly, and when there is not the slightest turning outward 
of the lower lid, and consequent displacement of the lower 
canaliculus. 

Paralysis of both sides seems to be quite rare. I 
saw one case in connection with aural polypi on each side. 
The deformity was very remarkable. The face remained 
smooth, regular, cold, and without expression in laughing 
or crying; the under lids with greatly reddened edges were 
everted, while the cornea was very prominent and dry 
from want of covering; the thick swollen under lip 
hung down, allowing the saliva to drop out of the mouth, 
so that the chin was usually bound up with a handker- 
chief, and if the patient wished to speak or eat, he was 
obliged to hold it up with his hand. 

I have already called your attention to the fact, that an 
oblique position of the uvula, and an abrupt bending of 
it to one side, while it is also somewhat drawn up, may be 
often observed without any paralysis of the face; while in 
well-defined facial paralysis the position or elevation of 
the uvula may not be affected at all. 

We must finally mention that destruction of the walls of 
the vessels in the case of caries of the ear, often causes 
extravasations of various degrees, apart from slight 
hemorrhages, either in the ear, or from it, such as may 
occur in every case of the kind, and which cause the ming- 
ling of blood with the pus, so that the latter is of a dark 
brown color. Very severe and sometimes fatal bleeding 
from the ear has been several times observed from ulcer- 
ation of the adjacent vessels; the jugular vein, the trans- 
verse sinus, and especially of the internal carotid artery. 
The common carotid has been ligated several times on this 
account, and sometimes with a successful result. 



HEMORRHAGE FROM TRANSVERSE SINUS. 443 

An extremely interesting case of hemorrhage from the transverse 
sinus, through the nose and ear, was described by Koeppe in the 
Archives for Aural Surgery. 1 The connection, in this case, between 
the cavity of the tympanum and the sinus did not occur from actual 
caries, but from atrophy of the bone, the result of pressure. The 
passage outward of the secretion constantly forming in the cavity of 
the tympanum was prevented by polypoid granulations, and downward 
by swelling of the mucous membrane of the tube. " From the cavity 
of the tympanum, thus shut off, a cyst, as it were, arose, whose 
interior membrane secreted a puriform material, which gradually in- 
creased, exerted a constantly increasing pressure from within, and 
caused the bony wall to disappear." 

All these various forms of disease that we have been 
studying as frequent consequences of caries of the petrous 
portion of the temporal bone, may, however, perhaps with 
the exception of destruction of the walls of the larger 
vessels, arise from suppuration of the ear, even without 
an affection of the bone, simply through morbid processes 
within the vascular apparatus. 

Very many observations have long since rendered it 
quite certain, that otorrhoea very often leads to fatal 
disease, when no trace of caries of the bones of the 
ear is found in the cadaver. In order to explain this 
fact, we must remember that the lining membrane of 
the auditory canal and the cavity of the tympanum, that 
is, the tissue from which the suppuration in the ear 
takes place, has the same nutritive importance to the 
temporal bone that the peri-cranium — the outer cover- 
ing of the skull — has for the other bones of the cranium, 
and that the vessels of the peri-cranium, by means of the 
diploe, are connected to those of the endo-cranium, that 
is, to those of the dura mater. 

The diploe, therefore, with its partitioned cellular 
spaces, is a connecting link between the soft parts of the 
ear on one side, that is, the purulent collection, and the 

1 A. F. O., II, s. 181. 



444 METASTATIC ABSCESSES. 

dura mater, with its venous sinuses on the other, since 
the venous net-work of the diploe not only obtains its 
blood supply from both sides, from without and within, 
but the larger osseous veins proceeding from it, the venae 
diploicae, also empty in part into the external veins, and in 
parts inwards into the sinuses. 

You will now comprehend, that, in consequence of 
inflammationof the soft parts of the ear, disturbances of 
nutrition in the dura mater as well as in the walls of its 
vessels — meningitis, as well as phlebitis — may easily occur. 
But that affections of the walls of the veins may cause 
further morbid processes within the vessels, which may 
lead to continuous morbid processes in the channels of the 
blood, is sufficiently well known to you. 

We may often seek for the point of origin of various 
constitutional affections — which declare themselves under 
cerebral, typhoid, and pyaemic symptoms, and which ap- 
pear on the post mortem table as metastatic abscesses and 
deposits, and as ichorous inflammation — in the most dif- 
ferent structures, in the diploe, and in the other cellular 
portions of the temporal bone. 

Surgeons have always known that even a seemingly 
trivial injury of the hard or soft parts of the head is to be 
seriously regarded, because it often leads to abscesses and 
inflammations in remotely situated organs, which may have 
a fatal result. At a very early period it was known that this 
was due to a certain participation of the diploe in the affec- 
tion. Now, by means of the labors of Virchow, which have 
broken an entirely new way in the field of science, and 
made, as it were, an epoch in pathology, we know that 
next to the veins of the lower extremity, and of the pelvis, 
there is no part of the human body so favorably circum- 
stanced for the formation of blood-clots, as the blood-ves- 
sels of the dura mater, and the net of capillary vessels com- 
municating with them, which pass through all the cellular 



METASTATIC ABSCESSES. 445 

structure of the bones of the skull, filling them, and thus 
making them very vascular organs. It is very plain that 
such a formation of plugs of fibrinous material, will be very 
much favored by inflammation of the diploe, such as easily 
results from the disturbances of nutrition of the adjacent 
soft parts of the ear, that are in immediate vascular con- 
nection. 

The importance of osteo-phlebitis of the diploe, which 
is so greatly feared by the surgeon, depends for a great 
part on the action of purely mechanical causes. The 
vessels of the diploe are, in many places, if not every- 
where, adherent to the unyielding bony wall, and thus, in 
consequence of hindrance in the contraction of the vessels, 
thrombi, plugs of fibrinous material are more easily formed 
in them, which extend into the sinuses by further growth, 
are then more fully developed, are finally carried forward, 
and having become wedged in the current of the pulmonary 
vessels, excite metastatic inflammation there. 

In such cellular spaces as those which surround the audi- 
tory canal and cavity of the tympanum, purulent masses 
are apt to remain, deliquesce, and frequently lead to ex- 
travasations and subsequent coagulations of blood, which 
again act upon the contents of the sinuses, through the 
larger osseous veins. They also cause the development of 
real infectious masses, which pass into the circulation and 
1 excite the well-known pyaemic and septic metastases in the 
pleural and articular cavities. 

If, however, more exactly speaking, a great part of the 
hollow and reticulate spaces of the temporal bone are not, 
in adults, to be considered as diploetic, since they contain 
air, and do not enclose a thin fluid medulla with a 
minute vascular net-work, still we have here, when inflam- 
mations and suppuration occur, anatomical conditions very 
similar to those in diploetic structure, and the cavities of 
the temporal bone, especially in the existence of perforation 



44-6 INFLAMMATION OF VEINS. 

of the membrana tympani, are in free connection with the 
atmospheric air. This connection, of course, favors the 
deliquescence as well as coagulation of blood in the injured 
vessels. The petrous bone of the child, however, consists 
almost entirely of diploe. 

In England, it was long since time shown, that patients 
suffering from otorrhoea, die in consequence of purulent 
pleuritis, with pyaemic symptoms, and with lobular ab- 
scesses of the lungs, and that phlebitis of the cerebral 
sinuses of the jugular vein was an explaining accom- 
paniment. Lebert first called our attention in Germany 
to these common results of inflammation of the ear, 1 and 
he attempted to show the deleterious influence of phlebitis 
on the blood channels, since, from them the inflammation 
must extend to the membranes and to the brain, or to the 
jugular vein and the lungs. 

According to Lebert, inflammation of the venous 
sinuses first declares itself by a chill which suddenly occurs 
in the course of an otorrhoea, in connection with other 
symptoms of an incipient typhoid fever. Generally such 
cases are considered as true typhus. The pain in the head 
is much severer, however, it is confined to one side, and is 
increased on pressure. There is often delirium, appearing, 
like the pain at intervals, and varying with the symptoms of 
cerebral depression. In the same manner the symptoms of 
weakness and paralysis of the limbs are of a weak and 
oscillating character. All the peculiar typhus symptoms, 
such as roseola, ilio-caaecal pain, enlargement of the 
spleen, diarrhoea, typhoid bronchitis, etc., are wanting. 

The vacillating character of the malady, as it ex- 
tends with regularly accelerated pulse into the first and 
second week, as well as the continued, or at least occa- 
sional pain in the ear, gradually call attention to the ear 
and brain. If the affection do not lead to sudden 

i Virchow's Archiv, Bd. IX, 1855. 



INFLAMMATION OF VEINS. 447 

death in the form of meningitis, distinct pyaemic symp- 
toms appear in the course of the second or third week. 
The chills have so distinct a character, that many phy- 
sicians diagnosticate the affection as intermittent fever, but 
a regular interval never appears, while the typhous ex- 
haustion, the cerebral symptoms, and the remarkable 
weakness of the pulse continue, and gradually the symp- 
toms of metastatic abscesses in the lungs and joints 
appear; sometimes they appear also in the subcutaneous 
connective tissue. In the first stages of the disease there 
is a tendency to constipation; later on, diarrhoea occurs; 
the evacuations are irregular, and death, in a comatose 
condition, generally occurs. 

The course of this disease is either a rapid and acute 
one — which we might call the meningitic, because the cere- 
bral symptoms are most prominent — or it is of a typhoid 
and pyaemic character, malignant to the highest degree, 
lasting to the fourth or fifth week. 

Virchow has taught us, since then, that the putrid ma- 
terial in the blood — and not the inflammation of the walls 
of the veins, the phlebitis, although of course assisted by 
this — is the chief cause of the disease. I have thought it 
well, however, to give Leberfs description of the course 
of the disease in full. It must be clear to you that these 
consequences of otorrhoea, thus described, and whose origin 
may be referred to emboli and septic infection, that is, to 
morbid processes in the circulatory system, may appear 
without any caries of the temporal bone. 

You will often, especially in the French authors, for 
instance, in the works of Rilliet and Barthez on Diseases 
of Children, read of tuberculous caries of the petrous 
portion of the temporal bone, as a common cause of 
otorrhoea, which leads to a fatal result under the name 
of pyaemia or meningitis, especially in children. In the 



448 TUBERCULOSIS OF TEMPORAL BONE. 

post mortem examination we find tuberculous deposits 
in the ear in great masses, and encysted tubercle in the 
mastoid process: cc Mature tuberculeuse infiltree ou encystee." 
The whole inflammatory process, the ulceration of the 
membrana tympani, the otorrhcea, with all its results, were 
considered as resulting from the softening of the tubercle, 
which was regarded as the primary process. 

In a more exact examination the most of these cases 
have another signification. There is certainly a tubercu- 
losis of the bones, and we cannot deny the possibility of 
a tuberculous affection of the temporal bone; yet the occur- 
rence of such an affection is very rare. We must recollect 
that thickened pus and softened tubercle resemble each other 
very much. You know, gentlemen, that wherever pus 
is collected in any great mass, it becomes thickened and 
partially calcified, because the great amount of the sub- 
stance does not allow of its complete breaking up and 
resorption. At the most, a part undergoes fatty degenera- 
tion, the remainder is calcified and the thickened pus 
then forms a cheesy mass, such as may be also developed 
from tubercle. These cheesy masses, of entirely different 
origin, are very often confounded, and to the unassisted 
vision they are scarcely distinguishable. Exactly here — in 
the cavities of the auditory apparatus, and in the cellular 
spaces of the mastoid process — are found large masses of 
pus, which gradually shrink up and form a cheesy-like sub- 
stance; and perhaps the most of the cases designated in 
the literature as tubercle of the temporal bone are such 
deposits, which owe their origin to a long-continued and 
purulent inflammation, and their undisturbed formation, 
to a rare use of the syringe. 

Dr. Zaufal 1 describes a case of " primary tuberculosis of the 
petrous bone," in a patient who died of phthisis pulmonalis. The 
tuberculous mass was embedded in the dense bony structure of the 

1 Archiv fur O., II, s. 174. 



TUBERCULOUS MENINGITIS. 449 

anterior surface of the pyramid, and was not connected to the 
cavity of the tympanum, the cells of the mastoid, nor the cavity of 
the labyrinth. 

However, even if such formations are not tuberculous, 
they have a very pernicious importance, as well for the 
neighboring parts as for the whole organism. It is well 
known also that these cheese-like masses sometimes soften 
and produce an ulcerated condition, from which, according 
to Professor Buhl's observations, acute miliary tubercu- 
losis of the lungs and other organs may be developed. 

I have observed that a comparatively large number of the very 
many persons sufFering from chronic otorrhoea, that I have kept 
under my eye, went into a state of general decline, and died quite 
quickly in the best years of life. Acute tuberculous meningitis, 
tuberculosis of the lungs, or of the intestines, was generally found in 
those cases that were examined after death. In publishing three 
such cases in Virchow's Archives, some years ago, I felt compelled 
to ask, " If some forms of tuberculosis beginning suddenly, and hav- 
ing a speedy course, might not depend on an infection of the blood 
from some purulent collection." As I afterward learned, Professor 
Buhl, 1 of Munich, not only asked this question, but, supported by 
facts, avowed himself as having this view, at least as to the occur- 
rence of miliary tuberculosis. The anatomy of the parts leaves 
scarcely any doubt that the middle ear is particularly well adapted to 
serve as the point for the purulent collection, if pus lie in its cellular 
spaces and undergo calcareous degeneration. Schwartze* has re- 
ported several cases, with the results of the post mortem examina- 
tion, where tuberculosis of the lungs was developed very rapidly in 
persons sufFering from otorrhoea. 

There seems to be a similar condition of things, accord- 
ing to Virchoiv s examinations, in regard to the cholesteato- 
mata y or the molluscous tumors (J. Miiller), or Mollusca 

i Wiener Med Wochenschrift, 1859, s. 195. 

* Archiv fur Ohrenheilkunde, II, 4, s. 280, et seq. 

57 



45° METAMORPHOSIS OF TISSUES IN EAR. 

Contagiosa (Toynbee), which occur in the petrous bone. 
Virchow advises the substitution of the original name 
pearl-like tumors (P erlgeschewiilste) for these terms. These 
are mother-of-pearl, shining, onion-like, layered tumors, 
in the posterior section of the temporal bone, which ex- 
tend through the bone to the external auditory canal — 
sometimes, also, into the cranial cavity — as a rule, existing 
with chronic otorrhoea, which usually has a fatal result. 
Examination proves that they are composed of flakes of 
epithelium, mingled in various proportions with choles- 
tearine. It appears that here, also, we have to deal with 
inflammatory products, furnished for the greater part by 
the superficial surface of the auditory canal, which product 
is gradually accumulated, dries, and by means of continued 
peripheral growth, develops itself more and more into a solid 
body, which acts as an offending substance, and byitspressure 
wears upon the adjoining parts, causing them to disappear. 
Since there is only a vacant space posteriorly in the tem- 
poral bone, such a dried mass of secretion provides itself 
with a closed space in that position, until, if its growth be 
not disturbed, it extends, posteriorly, upon the petrous 
bone itself, upon the sinus transversus, or upward against 
the brain, and thus produces a fatal result. 

Wherever fatty products are for a long time shut off 
from any change in material, or metamorphosis, and become 
stagnant, we see, as is well known, cholestearine formed 
from them. The pus in the ear furnishes a considerable 
quantity of fat, as does also the secretion of the numerous 
sebaceous and ceruminous glands, and the experience of 
all pathological anatomists, from Rokitansky on, as well as 
that of aural surgeons, prove that in the external and mid- 
dle ear extensive formations of cholestearine are something 
very common. 

When we considered the diseases of the external audi- 
tory canal, we saw that the peripheral layers of a mass of 



PEARL-LIKE TUMORS. 45 I 

impacted cerumen often have a shining appearance, and 
consists of cholestearine crystals, which may be very often 
found in all cerumen. We often, also, may see cholestearine 
as glistening points floating in the water, if we syringe an 
ear affected with otorrhoea. 

I have sometimes found the deep parts of the auditory 
canal filled with flat, whitish bodies, the removal of which 
required several days with the help of a delicate spatula, 
or a Daviel's spoon, and which were accretions of epidermis, 
with the well known large rhomboid plates. 

It seems to me probable, after all that has been said 
upon the subject, that pearl-like tumors in the petrous 
bone 5 just as we have seen is the case in "tubercles of the 
petrous bone," result from the collection of a superficial 
inflammatory product, and that they are a kind of reten- 
tion tumor. 

It is possible that such a tumor must often be con- 
sidered as an independent neoplastic formation, from 
which the inflammation of the ear has secondarily pro- 
ceeded. It should not be forgotten that such cholesteato- 
mata have several times been observed entirely separate 
from the outer surface of the body, e. g., in the interior 
of the skull. However, we may well ask the question 
whether various kinds of growths have not been freq- 
uently confounded by the names cholesteatomata, or pearl- 
like tumors. 



LECTURE XXVI. 

PROGNOSIS AND TREATMENT OF SUPPURATION IN THE EAR. 

Difficulty of the diagnosis, "caries of the petrous portion of 
the temporal bone;" the relations of patients with otorrhcea 
to military service and life insurance companies; thorough 
cleansing of the ear; manner of using astringents, and their 
selection; consideration of the general condition; local blood 
letting; incision behind the ear and in the auditory canal; 
secondary affections of the auditory canal; trephining the 
mastoid process; its indications and history; removal of 
sequestra. 

Gentlemen: As we have just seen, the prognosis, and, 
I may add, the therapeutics, in suppuration of the ear, do 
not depend very much on the transition of the inflamma- 
tion of the soft parts upon the bones, since experience 
shows us that nearly all the consequences of otorrhcea that 
have been mentioned, occur just as well with, as without 
caries of the petrous portion of the temporal bone. In 
view, however, of the great importance ascribed by practi- 
tioners, in general, to caries of the petrous bone, although 
very little is attached to a pure otorrhcea, we may spend a 
little time in discussing the difficulty in diagnosticating 
the former affection. 

Caries. — Apart from the cases where the parts affected by 
caries are readily seen, on an examination of the ear, and 
these are rare, it is not an easy matter to decide whether 



CARIES OF TEMPORAL BONE. 453 

the inflammatory process has led to softening of the sur- 
face of the bone. We should be careful, especially, not 
to fall into the error of considering every case of otorrhoea 
where there is a bad odor, as connected with caries, as is 
very frequently done. 

The longer a puriform secretion remains in the ear, and 
the more material it possesses for the formation of the 
fat acids, the more unpleasant will be its odor. We 
therefore find the most disgusting smell in cases of 
suppuration in the auditory canal, ears that are not kept 
clean, as a result of the secretion of sebaceous material and 
ear wax. It is perceived in cases where only the soft parts 
are affected, and when, as we may assure ourselves by 
ocular inspection, the bone is not at all involved. 

The most common, but, in unpracticed hands, the most 
dangerous, means of deciding as to the existence of caries 
in the deeper parts of the ear, is the use of a probe. 
The use of such an instrument should be avoided if the 
eye be not made to guide the hand, that is, if the parts to 
be touched cannot be well illuminated. If the parts are 
so situated that we can see them, an inspection will teach 
us more than any amount of probing, which frequently 
causes hemorrhage, and easily excites pain. We remember 
how thin the labyrinth wall is at the point which lies oppo- 
site the membrana tympani. If we add to this, that it is 
morbidly softened and tender, we can conceive that only a 
slight amount of pressure may cause an opening of the 
cochlea or vestibule. This would be dangerous to the life 
of the patient, since a way would be thus opened for the 
passage of pus to the meatus auditorious internus and 
the cavity of the cerebrum. 

But, if by bending the probe we bring it in contact 
with parts beyond the eye, there is danger of making a 
false passage, anteriorly into the carotid canal, upward 
into the cranial cavity, or downward to the jugular vein, 



454 CARIES IN THE EAR. 

and without any satisfaction of the professional desire for 
knowledge. 

As a rule, then, the use of the probe is of no service in 
the diagnosis of caries of the ear, while great harm may 
be done with it. Of course the matter is quite different in 
abnormal conditions of the outer ear, where we frequently 
can not dispense with the probe, in order to ascertain the 
boundaries of polypi or sequestra, whether they have a 
free or fixed position, and so on. 

The one certain evidence of caries in the ear, that is 
not ocular, is the presence of bony particles in the pus. 
The appearance of elastic fibers in the discharges (Moos), is 
an untrustworthy proof, since they occur in profusion in the 
cuticular layer of the auditory canal, and the membrana 
tympani, as well as in the envelope and tendon of the 
tensor tympani muscle. Frequent mingling of blood with 
the pus, when no polypus exists, and no injury has occurred 
to the parts, from a probe for example, is a suspicious cir- 
cumstance. Certain pus secreting surfaces, especially a 
granulating membrana tympani will bleed, however, even 
after they have been simply syringed with warm water. 

I have often noticed that a solution of lead that has 
been dropped into the ear, was black colored at the same 
time that a suppurative process in the ear assumed an 
unpleasant aspect, and that on the other hand, this dis- 
coloration did not occur when the morbid process appeared 
to be becoming better. It is possible that we have, in 
a solution of lead, a sort of a reagent for caries. We may 
conceive of a union of sulphur or phosphorus with the 
lead, for which the material is furnished by the softening 
and disintegration of the surface of the affected bone. 

When mucous flocculi are chiefly evacuated, in syringing, 
which float about in the water without dissolving in it, we 
can scarcely imagine that any extensive ulceration exists. 



CARIES IN THE EAR. 455 

In other respects the external properties of the secretion 
scarcely ever furnish any positive conclusions. 

Besides the general probabilities depending upon the 
course and duration of the disease, and the general health 
of the patient, the kind of pain has a certain importance. 
It is often exceedingly severe in caries of the petrous bone. 
It is described as a pain that bores into the deep part of 
the ear. It may continue for days and weeks without 
interruption, and appear suddenly at night without any 
evident cause. If a pain of this kind occurs, which is 
very frequently accompanied by only a very slight discharge, 
and frequently returns without any external cause what- 
ever, and without any evidence of recent inflammation of 
the soft parts, if it cannot be referred to a displacement of 
the opening of the membrana tympani, or any other cause 
for retention of the secretion, we may always think of 
caries of the bone as one of the possibilities, and yet this 
symptom is no certain diagnostic evidence of its existence. 

I have made post mortem examinations in cases of 
caries of the ear, that existed for years without any pain 
whatever, and where it was only at the close of the scene 
that it occurred, and then with dreadful and increasing 
severity. It is a suspicious symptom, when the instillation 
of even weak astringents always causes pain in the ear. 

Prognosis. From what has been said, you see how 
careful and reticent we must be, in regard to the prognosis 
of chronic otorrhoea, since we can never say with certainty, 
how far deeply seated morbid changes may have gone on, 
which from the nature of things lie beyond our therapeutic 
aid. Wilde very well says: cc So long as a discharge from the 
ear exists, we are never able to say, how, when or where it 
may end, nor to what it may. lead." 

In opposition to such an earnest appreciation of the 
affection, you will find, that the most of the profession, 



456 IMPORTANCE OF OTORRHCEA. 

even more than the laity, regard an otorrhoea as quite a 
trifling affection, and as scarcely worth the trouble of any 
continued treatment. A suppuratingwound in the outer 
surface of the skull, after an injury, for example, is 
certainly considered worthy of attention by every surgeon; 
the same condition in the interior of the head, in a space so 
narrow and so irregularly formed that the pus very readily 
becomes fetid, in a situation that is adjacent to so many 
important parts, is very often thought worthy of only a 
few consolatory words, or a contemptuous shrug of the 
shoulders. 

A person suffering from a chronic discharge from the 
ear, should not be subject to military duty, because he is 
exposed in the performance of this service to many inju- 
rious influences which may cause his life to be in danger. 

Several English life insurance companies decline to 
insure the lives of persons affected with otorrcea. This 
refusal must be considered as perfectly justifiable, and as 
one that might well be imitated by our German companies. 
Every case of suppuration in the ear may under certain cir- 
cumstances lead to an affection that is dangerous to life, and 
we do not always possess the power of preventing such 
consequences. From the stand-point of life insurance 
companies it should also be considered, that even large 
abscesses in the brain and other common consequences of 
purulent inflammations of the ear, may be developed in a 
latent manner, so that their existence is not suspected 
until just before death occurs. 

Generally speaking, we may say, that cases where there 
is a large loss of substance of the membrana tympani are 
the least in danger of deeply seated affections, if the exit 
be not interfered with by polypoid growths or by an accu- 
mulation of the secretion. The latter may occur by an 
adhesion of the posterior or upper border of the perfora- 
tion, in a manner that is with difficulty recognized during 



CHILLS IN OTORRHCEA. 457 

during life. It is a retention of the pus, that most fre- 
quently leads to dangerous consequences. There are, 
indeed, cases recorded, where patients suffering from 
otorrhoea, have finally recovered after the continued existence 
of typhoid symptoms, with chills, metastatic abscesses, 
but these cases are certainly exceptions. 

Prescott Hewitt has recorded one of the most interesting of these 
cases. 1 In connection with very severe typhoid fever and chills, there 
was decided pain in the course of the jugular vein, and abscesses 
formed in the sterno-clavicular and hip articulation. Inflammation 
of the knee joint, and symptoms of pneumonia were also added. In 
spite of all this the patient gradually recovered under the use of wine 
and morphine. 

Fortunately, such consequences as we have been con- 
sidering, only occur as a rule in cases that have existed for 
some time. They may, therefore, usually be prevented by 
an appropriate and early treatment of the original affection. 
Even in a very old case of otorrhoea, we may often do a 
great deal of good in opposing the extension of the 
inflammatory process. Very frequently, as our previous 
observations have shown, the hearing is greatly improved 
by treatment. I may finally warn you not to immediately 
make an unfavorable prognosis, when a slight chill occurs 
in the course of an otorrhoea. 

Treatment. — The treatment of an otorrhoea consists 
above all things, in the thorough removal of the secretion. 
We may use simple luke-warm water, for the purpose of 
injecting the ear. When the cavity of the tympanum is 
exposed, we may add a little common salt to the water. 
The disadvantage of using chamomile tea (much used in 
Germany, but not in the United States), as well as other 

i London Lancet, Feb. i, 1861. 

58 



45§ TREATMENT OF OTORRHCEA. . 

decoctions, is that they leave organized material in the ear, 
which favors the disintegration of the secretion. 

The necessary injections with luke-warm water should 
be made very carefully, since a heavy stream from a large 
syringe may easily do great damage, in the sensitive and 
relaxed condition of the parts. Sometimes, even when 
the greatest precautions are taken, vertigo and fainting 
result from these injections, even in cases where the mem- 
brana tympani is not perforated, and the fluid does not 
enter the cavity of the tympanum. In some cases, the 
ear is more easily cleansed by the use of a small cameFs- 
hair brush, especially when the secretion is small, or there 
is a tendency to the formation of furuncles in the auditory 
canal. 

In all cases where pus is formed in the cavity of the 
tympanum, and this occurs in by far the greater number 
of discharges from the ear, this sort of cleansing of the 
ear will not be sufficient, especially when the opening in 
the membrana tympani is small. Such a small opening 
prevents both the passage of the pus outward, as well as 
the entrance of the cleansing stream of water. 

Where we are dealing with a purulent catarrh of the 
middle ear, the pus should be forced from within outward. 
This may be sometimes done in a very simple manner, by 
causing the Valsalvian experiment to be practiced by the 
patient* before the syringing is undertaken. It is better, 
however, to employ Politzer's method or the air bath by 
means of the cathether, which may be followed by the 
injection of salt water through the Eustachian tube. If 
there is a perforation on both sides, in cases where the use 
of the cathether is not practicable, especially in the case of 
young children, forcible injection of a weak solution of 
common salt into the nose, according to Gruber s recom- 
mendation may be of use. 

By such means, all the secretion that does not lie in the 

i 



TREATMENT OF OTORRHCEA. 459 

most posterior portion of the cavity of the tympanum, 
and in the cells of the mastoid process, is thoroughly 
driven into the auditory canal, and at the same time the 
natural passage for the running off of the secretion, the 
Eustachian tube is kept open. 

The ear should be thoroughly cleansed once or twice a 
day, or even oftener, according to the amount of the suppu- 
ration. Not unfrequently we may syringe the ear and 
cleanse it with a camel's-hair brush in alternation. If the 
secretion be very thick, or if we desire to remove a large 
amount that has collected, it will be well to fill the ear with 
warm water for some time before the syringing is under- 
taken, in order that the secretion may be better dissolved 
and more easily removed. If the patient lies on his back 
at the same time, a portion of the water wiU pass into 
the mastoid cells, in which great quantities of thick- 
ened secretion are often found, and we may thus suc- 
ceed in cleansing the whole middle ear as thoroughly as 
is possible. 

Astringents. — In not a few cases, especially in recent 
ones, the suppuration decreases under the simple cleansing 
of the ear ; it may even cease entirely and the perforated 
drum be healed. It is more frequently necessary, however, 
to act upon the tissue, which furnishes the abnormal 
secretion. This is generally accomplished by the means 
of astringents. A mere instillation of astringent ear 
drops into the auditory canal is only sufficient in an affec- 
tion of the external ear, or when the perforation of the 
membrana tympani is a very large one. We must cause 
the astringent to act more thoroughly upon the mucous 
membrane in another way. 

We formerly accomplished this latter by the injection of 
astringent solutions into the ear, through the catheter. 
Politzer has recently shown us another method of bringing 



460 ASTRINGENTS IN OTORRHCEA. 

medicated fluids in contact with the mucous membrane of 
the middle ear, when the drum is perforated. The audi- 
tory canal of the patient, who inclines his head to the 
opposite side, is filled with the astringent solution, and 
then in one of the three methods, Valsalva's, Politzer's, 
or by the catheter, the air in the Eustachian tube is com- 
pressed. As soon as the air passes through the perforation 
of the membrana tympani, it appears in the auditory canal, 
which has been previously filled with fluid in the form 
of bubbles, and at the same instant, the astringent must 
enter the cavity of the tympanum. In this simple man- 
ner the fluid comes in extensive contact with the morbid 
mucous membrane. This method has the double advan- 
tage, that it may not only be employed by a physician, 
who is not very certain in his use of the catheter, but 
also by the patient himself or by his friends, at each 
use of the ear drops. In appropriate cases, weak 
astringent solutions may be also employed by Gruber's 
method. 

Choice of astringents. — Acetate of lead and liquor 
ferri sesquichlorati, take a first rank as to the power of 
diminishing secretion. Unfortunately, however, these 
agents are decomposed, partly by the air, partly by the 
purulent secretion, and thus form a precipitate in the ear. 
These deposits, which are usually white, seldom black, 
when resulting from lead, or of dark brown color from the 
iron, prevent a proper estimation of the condition by 
means of the discoloration which they cause. They may 
also cause irritation to the inflamed parts, and a retention 
of the secretion. Finally, they may unite with the relaxed 
and inflamed mucous membrane itself, and cause perma- 
nent deposits, such as we sometimes see on the cornea, 
from the inappropriate use of eye drops. 

Such deposits on the membrana tympani, and in the 



ASTRINGENTS IN OTORRHCEA. 46 1 

cavity of the tympanum, may impair the functions of the 
ear by diminishing the elasticity of the vibrating parts. 
Whenever, then, there are any excoriations of the drum, 
or it is perforated, it will be well to entirely avoid the use 
of these two agents, especially when the medical attendant 
can not himself cleanse the ear every day, and remove all 
metallic deposits that may occur. 

Recently I have begun to employ solutions of lead again. If we 
add an equal quantity of acetic acid to the acetate of lead solution, 
the white deposit from the carbonate of lead does not form. 

When the proliferation of tissue is limited in extent, 
we may, however, use the solutions of lead as well as the 
liquor ferri, by pencilling it on the parts with a camel's- 
hair brush. 

Sulphate of zinc is a very useful astringent, when em- 
ployed in the proportions of from one to six grains to the 
ounce of water. The acetate of zinc is very frequently 
too irritating in its effect, even in very weak solutions. 
Toynbee recommends the chloride of zinc, and Ran the 
sulphate of copper, especially when caries of the bone 
exists. I would advise the further trial of plumbum nitri- 
cum^ which has at times done me very good service. 

Solutions of common alum are not always certain in 
their effect. They also have the disadvantage that they 
often cause furuncles to occur in the canal. The acetate 
of alum is to be preferred. It is well to use it in a fresh 
state, made from acetate of lead and alum. 

Politzer has recently advised the use of powdered alum. 
I have observed very speedy diminution of the secretion, 
and even the shrinkage of small granulations after its em- 
ployment. In order that the powder may get in the ear 
as deeply as possible, and not be checked at the cartilagin- 
ous portion of the canal by the hairs, an ear speculum is 



462 ASTRINGENTS IN OTORRHGEA. 

first introduced, the head of the patient inclined to the 
opposite side, and the powder gradually introduced, in 
small quantities, from an ear spoon. The irritation pro- 
duced is very slight, and the powder may be left a day or 
more in the ear, when the ear should be thoroughly 
cleansed, because the alum, with the secretion, will form 
fine lumps. I have never observed that furuncles occurred 
after such a use of alum. I have used crude, pure and 
burnt alum in this way, but without any great difference 
in the effect. 

Hinton, of London, advises absorbent powders simply, 
and for this purpose employs calcined magnesia, with the 
addition of a little morphine. (I have used the latter 
agent, without the morphine, however, and with good 
effect. St. J. R.) 

A weak solution of nitrate of silver is far inferior to the 
astringents that have just been named, apart from the fact 
that it discolors the parts so much as to render accurate 
observations of the case somewhat difficult. Stronger 
solutions, however, of from twenty to eighty grains to the 
ounce, do very excellent service, especially in very obsti- 
nate cases of otorrhcea. The solution should be neutral- 
ized by the subsequent injection of salt and water. The 
irritation following is generally either none at all, or very 
slight. Sometimes, however, the pain is considerable, but 
I have seen no other disadvantage following the use of 
such solutions. It is a means of using an astringent that 
may be generally recommended. I have to thank my 
esteemed friend H. Schwartze, of Halle, for its suggestion. 
Mineral astringents are usually to be preferred to the 
vegetable. Tannin alone, of the latter, occasionally does 
good service. 

Since all astringents lose some of their efficacy after 
long-continued use, we can not usually employ the 
same ear drops longer than from four to six weeks. A 



TREATMENT OF OTORRHCEA. 463 

great number of such agents, from which to choose, is 
therefore necessary, where the case is one of long duration. 
Before we proceed to the use of a new agent, it is well to 
let a few days pass without the use of any, because expe- 
rience seems to show that the new agent will then produce 
more effect. 

It is not well to use the astringent for syringing the ear. 
The ear is simply syringed with luke-warm water. If 
there be a very great odor to the pus, we may at the most 
add some tar water, chlorine water, liquor kali hypermang 
anici, or a solution of chlorinated soda, to the fluid to be 
injected. The astringent is then dropped in, the head 
being turned to the opposite side, and allowed to remain in 
the ear from five to ten minutes, during which time, if a 
perforation of the membrana tympani exists, the air should 
be forced into the ear several times. 

Constitutional treatment. — The general condition of 
the patient should be carefully considered in cases of sup- 
puration in the ear. There is no form of aural disease 
where general treatment, such as a system of baths, change 
of air, and especially a continued residence in a warm 
climate, do so much to assist the local treatment. The 
latter, however, is the chief thing, and with people who 
are in other respects healthy, will be sufficient of itself. 
Where decided and far advanced phthisis pulmonalis ex- 
ists, the most careful local treatment is at times without 
influence upon the amount of secretion. In such cases a 
very rapid deliquescence of the membrana tympani is 
sometimes observed, against which our efforts are utterly 
ineffectual. It is a very striking fact that in patients with 
tuberculosis, very great destruction of the membrana 
tympani, without any pain, sometimes occurs in a very 
short space of time. In such cases nothing can be done 
except to induce the patient to go to a better climate. 



464 TREATMENT OF OTORRHCEA. 

A depressing system of treatment, that is, a diminution 
of the ingesta, with increase of the excretion (inunction 
and sweating cures), very rapidly diminish the suppura- 
tion in the ear, as you would naturally suppose, but such 
a method of treatment will hardly do any permanent good 
to the patient, and may do harm, by diminishing his 
strength. 

Local blood-letting. — If sub-acute attacks occur, local 
blood-letting, together with light diet and purgatives, will 
be the best remedies. In the existence of deep-seated dis- 
turbances of circulation in the ear, the artificial leech may 
be applied on the mastoid process. The benefit from 
such a local blood letting is frequently very marked. I 
recall a case where, in the course of an otorrhcea that had 
existed for years, a paralysis of the facial nerve suddenly 
occurred, which disappeared immediately after Heurteloupe s 
artificial leech had been applied to the mastoid process. 

When, in the course of an otitis, with or without 
otorrhcea, the mastoid process begins to be painful, and 
tender on pressure, and the swelling and redness of its 
covering indicate an inflammation of the bone, lying 
under, a free incision of the soft parts down to the peri- 
osteum, is often of great use. Wilde recommends this 
procedure as one by which a process dangerous to life may 
be restrained, and I have had opportunities to test the use 
of such incisions. 

(In the New York Medical Press, vol. II, p. 833, occur 
some clinical remarks of Prof. A. C. Post on the subject 
of post-aural inflammation, which show a full appreciation 
of the affection. 

"Patient, aged 30, came to the Professor's clinic on 
account of pain in his ear and about it. 

"We have here, gentlemen, a swelling behind the ear, 
involving the deeper tissues, called a post-aural inflamma- 



INFLAMMATION OF MASTOID PROCESS. 465 

tion. It is very dangerous in its character if not properly- 
attended to, having the general character of a paronychia. 
If not relieved by incisions it will involve the bone, cause 
necrosis, extend to the encephalon, and with great suffering 
cause the death of the patient. I once attended a young 
girl approaching maturity, with prae-aural inflammation, an 
affection of the same character with the present case, in 
front of the meatus auditorius externus. It went on to the 
destruction of the anterior margin of the external meatus, 
but the patient recovered with a loss of bone. A sister of 
this same patient was attacked with the same affection, and 
died from its extending to the encephalon. She was not 
under my care, but the case came to my knowledge. 

" Incisions should be made fairly down to the bottom 
of the parts, so as to allow free exit to the matter, and 
relieve the tension. Such an incision was then made 
between the course of the occipital and posterior auricular 
branches of the external carotid. Pus was found next to 
the bone." St. J. R.) 

The incision must be long enough and be made with a 
powerful hand, in order that the periosteum may be fully 
divided. The swollen condition of the parts often renders 
the depth to which the knife may reach, very considerable. 
The incision should be made parallel with the attachment 
of the auricle, so that the posterior auricular artery may 
not be injured. The haemorrhage may be considerable. 
If an artery spouts, it may be twisted. Even if there be 
no evacuation of pus, the discharge of blood will afford 
great relief, and better the condition very much. If the 
circumstances require delay, apply poultices. (I can 
imagine few circumstances admitting of delay, and my 
experience includes quite a large number of these cases. 
St. J. R.) 

A free incision into the soft parts of the posterior or 
upper wall of the bony canal is often of great value in 

S9 



466 INCISIONS IN AUDITORY CANAL. 

the treatment of an otitis media. As we have already 
seen, the posterior osseous wall of the auditory canal 
is chiefly formed by the mastoid process, while the hollow 
spaces of the temporal bone, connected to the cavity of 
the tympanum and the antrum mastoideum, extend into 
the upper wall. The bony cells of the middle ear thus 
extend very far externally, even to the cartilaginous meatus. 
From this cause the integument of the external meatus is 
often secondarily involved in suppurative processes in the 
middle ear. An abscess, after perforating the bone, which 
is sometimes very thin, may collect under it, or the cutis 
of the canal may be sympathetically affected, or undergo 
swelling and infiltration proceeding from the periosteum. 

I once saw a case where as a result of a very severe inflammation 
of the ear, a fistulous opening, which secreted a great amount of pus, 
existed on the upper wall of the meatus, very near the orifice. The 
pus had made its way through the cells of the temporal bone and 
avoided the membrana tympani. It would not be so easy for a 
primary abscess of the auditory canal to open internally, but such a 
case is possible. 

Even in cases where the color or sensitiveness of the 
auditory canal exhibits no evidence of inflammation, and, 
when we certainly have no abscess, I have often seen 
benefit result from a free incision into the soft parts of the 
canal, apart from the fact that it may be often indicated to 
allow an exit of the pus that has collected behind. If the 
swelling be relaxed and not very sensitive, we may remove 
the secretion by means of a camel's-hair brush (or a small 
stick or bit of wire, about the extremity of which cotton 
is twisted. St. J. R.) 

Occasionally, in consequence of very frequent or long- 
continued injections of the ear, a perfectly painless, relaxed 
condition of the integument of the upper wall of the 
auditory canal occurs, which causes it to sink downwards. 



TREPHINING THE MASTOID PROCESS. 467 

We should then avoid moist applications for some days, 
and cleanse the ear by means of the brush or cotton, until 
the normal condition of the ear returns. 

Trephining the mastoid process. — If we have reason to 
believe that there is a collection of pus in the interior of 
the temporal bone, and especially of the mastoid process, 
the treatment usual in abscesses in bone should be adopted. 
Where the circumstances require delay, we may endeavor 
to favor suppuration by applying poultices behind the ear. 
It is a much safer plan, however, in such cases, to perforate 
the mastoid process, and thus evacuate the pus externally. 

We not unfrequently, especially in children, see such an 
opening behind the ear form spontaneously, or — as we are 
accustomed to say, through the curative power of nature — 
and an immediate benefit accrue to the patient from the 
evacuation of deeply seated pus. 

If this operation has been forgotten, or has come into 
disrepute, it is because of its abuse in the preceding cen- 
tury, as well as in the peculiar and exceptional position of 
the literature of otology until a short time ago. 

Principles, which in other departments of medicine are 
accepted as rational, methods of treatment, which surgery 
views as absolutely necessary, under exactly the same cir- 
cumstances, were not applied to the ear and its diseases. 

In the greater number of cases it would be allowable to 
wait and see if the incision that has been recommended to be 
made behind the ear, or in the auditory canal, be not suffi- 
cient of itself to give a more favorable turn to the condi- 
tion, and we may then, in case of necessity, trephine the 
mastoid process a day or two subsequently. An incision 
is first made through the integument down to the bone. 
Where the bone is soft and brittle, a strong pressure from 
the knife, or a probe, will be sufficient to perforate it and 



468 TREPHINING THE MASTOID PROCESS. 

to enter the mastoid cells. Where the bone is thicker and 
stronger, a small gouge, or Lucaes gouge forceps may be 
used. It is only when the outer bony lamella is very thick 
and hard, or when the whole mastoid process is sclerosed — 
the hollow spaces being changed to a dense bony mass, as 
often occurs after the long-continued, deep-seated inflam- 
mation — that it will be necessary to use a trephine. 

Generally the object desired is to open the larger space 
that always exists close behind and above the cavity of the 
tympanum, called the antrum mastoideum, or horizontal por- 
tion of the mastoid process. The instrument is placed 
on the bone on a level with the upper border of the outer 
meatus, from one-fourth to one-half an inch behind the 
attachment of the auricle, and is worked slightly forward 
in a horizontal direction. By thus proceeding the dura 
mater and transverse sinus will be avoided. The depth 
to which we must go is sometimes very considerable. 

Of course great care is to be taken, and frequent pauses 
should be made before the bone is perforated, in order that 
we may not, as it were, fall into the mastoid cells with the 
instruments. When the dense outer bony plate is per- 
forated, any further work on the bony septa may be done 
by any strong forceps. 

After having in this way made a place of exit for the 
fluid pus collected in the interior of the ear, the thickened 
secretion and that which is constantly forming should be 
removed by injections. The wound should be filled up 
with charpie in order to prevent it from closing. By such 
a counter opening a thorough cleansing of the suppurating 
surface is rendered possible. We therefore find that in all 
the cases where recovery has occurred, that the otorrhoea 
which had existed for years soon ceased, and that the 
general condition of the ear was permanently improved. 

This operative procedure is to be reckoned among those 
which may be indicated in order to save life. As every 



TREPHINING THE MASTOID PROCESS. 469 

physician may feel himself compelled, under certain cir- 
cumstances, to open the larynx, or to operate for strangu- 
lated hernia, so there are times when the perforation of the 
mastoid process remains the only remedy which may pos- 
sibly save life. 

If we compare the slight amount of danger from the 
procedure, with the certainty that such a counter opening 
will aid in finally checking a purulent discharge from the 
ear, and with the fact that even very insignificant cases of 
otorrhcea may finally cause death, it is possible that perfo- 
ration of the mastoid process may be yet advised as a 
means of treating an obstinate otorrhcea, and for the re- 
moval of any collected secretion, even where there are as 
yet no threatening symptoms. The cause of death, in 
the case above indicated, is usually a collection of inspis- 
sated secretion in the antrum mastoideum. 

The longer a suppurative process has existed in the 
deeper parts of the ear, the more rarely a syringe has been 
used, and the smaller the external opening (which is usu- 
ally in the membrana tympani), the more probable will it 
be that a collection of dried and hardened pus has formed 
in the cavity of the tympanum, and in the large cells be- 
hind it. It should also be observed how frequently tuber- 
culosis of the lungs or other organs has been developed 
where these collections have occurred. (See page 444.) 
It is almost impossible to remove these collections in any 
other way than by perforation of the mastoid process, and 
the subsequent injection of the parts. We should remem- 
ber, finally, that the operation, according to the experience 
yet had with it, is by no means a very serious procedure. 

Historical. — Riolanus in 1649, and Rollfink in 1656, first pro- 
posed to perforate the mastoid process. It was only advised by both 
of these authors, however, in cases of deafness and tinnitus aurium, 
dependent upon occlusion of the Eustachian tube. Valsalva in 1704, 
was the first surgeon who injected a fistula already existing behind 



47° TREPHINING THE MASTOID PROCESS. 

the ear and thus cured a very obstinate otorrhoea. Petit and Huer- 
mann first advised the perforation of the mastoid process in the 
existence of caries and of a collection of pus in the part. jf. L. 
Petit is said to have first performed the operation by means of a 
gouge and hammer. 

The operation is best known through a military surgeon, jfasser, 
who in 1776, half accidentally perforated a mastoid process with a 
probe, after he had cut through the integument. He was enabled by 
means of injections through this opening to free a soldier from the 
most fearful pain, a febrile condition that had existed for weeks, and 
from an otorrhoea of years standing. This surgeon repeated the 
operation with a trochar under circumstances, and described his 
method. It has hence received the name of "Jasser^s operation. 
After this, the operation was performed by various surgeons, but 
almost always as a remedy for deafness without otorrhoea. The 
hearing of some patients was restored, and to none of them did any 
particular harm occur, so that the operation was generally considered 
as a useful one, and as unattended with danger, until a Danish surgeon, 
Berger, who suffered with every disturbing tinnitus and deafness, 
prescribed the operation for himself, and soon died of meningitis after 
its performance. Since that time (about the close of the last century), 
this operation which was at first enthusiastically undertaken, and 
performed without any regard to the cases for which it was adapted, 
has fallen into great discredit. 

Literature.— Troltsch Virchow's Archiv Bd., xxii, 1861, s. 295 ; 
Pagenstecher Archiv fur Klin. Chirurgie Bd., iv, s. 325, 529, 533; 
Turnbull, Medical and Surgical Reporter, Philadelphia, 1862, Feb. 
15; Scbwartze Prakt Beitrage ziir Ohrenheilkunde, s. 37; Mayer 
Archiv fur Ohrenheilkunde, I, s. 226, II, s. 228. 

Professor Von Bruns informs me that in two cases he has enlarged 
a small fistulous opening of the mastoid process, with a small 
trephine. 

Removal of necrosed bone. — The perforation of the 
mastoid process often only breaks the way for the removal 
of a sequestrum which lies deeply situated in it. The 
artificial or natural removal of a necrosed piece of bone 






REMOVAL OF SEQUESTRUM. 471 

from the auditory canal is not unfrequently necessary, in 
order to terminate a suppurative process in the ear. 

In this way, the entire osseous labyrinth, that is, that 
part of the petrous portion of the temporal bone which 
includes the cochlea, vestibule, and semi-circular canals, 
is quite often thrown off. There are a number of cases 
recorded where the patient not only was saved from death 
by the removal of the sequestrum, but also where he re- 
covered from various affections, e. g., from hemiplegia. 1 

(In the first American edition of this work I appended 
a case of the removal of the internal ear during life, re- 
ported by Dr. C. R. Agnew. Since it excited very considera- 
ble interest, and was copied into numerous journals from 
my translation, I have again added it to the author's 
account of these cases. The sad termination of the case 
from an exostosis of the auditory canal of the opposite 
ear, which caused a retention of the pus, and secondary 
meningitis, will be found recorded on page 131 of this 
work. 

W. C., 2 aged 38, had suffered from otorrhcea from the 
right ear for the greater part of thirty-two years. The 
origin of the disease was obscure. Considerable sense of 
hearing remained till three years before the case came 
under my observation, at which time an exacerbation of 
the aural inflammation, accompanied by prolonged and 
excessive pain deep in the ear, and through the neighbor- 
ing parts of the head, terminated in total loss of hearing 
in the affected organ, and paralysis of the corresponding 
portio dura of the seventh pair. 

Several times during the progress of the disease granula- 
tions sprouting from the depths of the external ear, out- 
cropped at the meatus, and were removed by torsion. 

1 Toynbee, A. F. O., I, s. 112; Troltsch, Virchow's Archiv, B. XVII, s. 475 Gruber, 
Allgemeine W. Zeitung, 1864, Nos. 41-45. 

* American Medical Times, Vol. VI, p. 183. 



472 REMOVAL OF SEQUESTRUM FROM THE EAR. 

The patient came under my observation for the first 
time, on the 16th April, 1862, presenting evidences of 
great suffering and debility. 

He had suffered greatly for months from growing pain 
in the ear, insomnia, loss of appetite and dizziness. An 
examination of the external ear was effected with great 
difficulty, on account of its excessive tenderness. The 
concha, swollen and inflamed, was elevated by a dense 
inflammatory tumefaction, circumscribing the external 
meatus, extending backward over the mastoid process, and 
forward along the zygoma. Projecting from the meatus 
was a large pear-shaped polypus of a dense fibrous cha- 
racter, bathed by a constant flow of stinking pus. De- 
siring to get to the bottom of the case, I placed the 
patient under chloroform, and removed the polypoid mass 
by means of a wire snare. In attempting to push the 
snare to the bottom of the meatus, I encountered a solid 
obstacle in the region of the middle ear, which subse- 
quently proved to be the sequestrum, represented by the 
accompanying wood-cut. The caliber of the external 
meatus had been greatly reduced by boggy swelling of its 
soft parts, so that I was compelled to make as free an in- 
cision as possible to enable me to reach the sequestrum ! 
with a pair of small dressing forceps. Having got the 
body in the grasp of the forceps, a slight rocking motion, 
with traction, enabled me to extract it. 

Fig. 36. 





It will be observed that the sequestrum includes the 
wreck of the labyrinth. The cochlea is shown laid open 






TREATMENT OF OTORRHCEA. 473 

by caries, and two of the semi-circular canals are seen in 
part. The loss of hearing and paralysis of the seventh 
pair were explained. Two views in facsimile are given of 
the sequestrum, in the wood-cut, and an attempt has been 
made by the artist to represent the eroded appearances. 

The remains of the anterior semi-circular canal are indi- 
cated by the letter C, the cochlea B, opened by caries, 
shows the lamina spiralis. The vestibule, E, A, D, is 
bereft of its furniture, and almost obliterated. After the 
operation, the patient rapidly regained his health, and by 
the 3d of January, 1863, the external meatus had become 
closed by cicatrization. The paralysis still remains. St. 

J. R.) 

Allow me a few words, now, as to the prejudice which 
exists among the laity, and which proceeds from the pro- 
fession, against stopping an otorrhoea, out of regard to the 
general health. I have always found, that with a gradual 
diminution of the aural discharge, the general condition 
is improved ; and that very many persons lose their lives 
because the disease is allowed to go on. 

When, for the first time, I saw an otorrhoea which had 
existed for years, disappear after the removal of a polypus, 
so to speak, in the twinkling of an eye, I took the precau- 
tion to order laxatives for a few days, or, in other cases, 
the establishment of an issue on the arm. One patient, 
disgusted with the uncleanliness, allowed the sore to heal ; 
another did not carry out my directions; neither case was 
followed by evil results. Since then I allow over-anxious 
persons to drink "bitter wasser" for some days, in order 
to quiet their fears, because I have learned that such a 
sudden cessation of the discharge is not productive of 
evil results. 

When there is no polypus, foreign body, sequestrum, 
or the like, and the otorrhoea, with our best efforts, will 
not cease, we may well regard any opinion of the surgeon 
60 



474 TREATMENT OF OTORRHGEA. 

against the sudden stoppage of the discharge, as very like 
that of the fox in the fable, as to the taste of the grapes 
which were beyond his reach. 

We can only treat a discharge from the ear successfully 
when we know the cause of the malady. Since this is 
often unknown, the treatment often fails to do the patient 
any good, and then the idea occurs to both the patient and 
the physician, that on the whole, it is better to leave the 
whole thing to good dame Nature. If a sudden lessening 
of an otorrhcea occurs at the same time with some general 
malady, it is immediately concluded that the sudden 
stoppage of the discharge is the cause of the disease. 
Cause and effect are here confounded; another reason must 
be sought for. The discharge ceased, because from some 
kind of an injurious influence, possibly from the use of 
an inappropriate, or too strong ear-wash, an acute inflam- 
mation of the ear has occurred. There is less purulent 
discharge, because it has suddenly made its way inward, or 
from the fact that m some mechanical way it has been shut 
up in the depth of the ear. This last cause for a diminu- 
tion of discharge produces the worse condition, and the 
affection of the brain. 

But, for the justification of the general practitioner, 
one more remark should be made. This erroneous belief 
that local remedies may easily do harm in otorrhcea, that 
they may cc suppress it," and that we should therefore 
attempt to subjugate the affection by internal treatment, 
has been for the most part encouraged by aural surgeons 
themselves, especially by those French authors who have 
in other respects contributed very much to our knowledge, 
DuVerney in 1683, and Itard m 1838. 



LECTURE XXVII. 

AURAL POLYPI. 

Their origin and structure; treatment. 

FOREIGN BODIES IN THE EAR. 

Most of the methods of extraction more dangerous than the 
foreign bodies; an operation proposed for doubtful cases; 
foreign bodies in the ear often the cause of peculiar reflex 
symptoms; several cases. 

Gentlemen: Among the forms of disease that not 
unfrequently keep up an obstinate otorrhoea, is polypus 
of the ear. Such a growth is usually developed in con- 
sequence of a long-continued suppurative process. I saw 
aural polypi develop in two cases, however, where there 
had been no purulent inflammation previous to their 
origin. 

Aural polypi may be described as vascular tumors, usu- 
ally of a bright red color, and roundish contour. They 
are sometimes very soft, and bleed on any contact with 
them. Again they are tense, and have a shining surface. 
Their structure is often grape-shaped, or lobulated. 
Sometimes they have a broad base, while at others they 
have a small pedicle. They vary exceedingly in density 
and size. In some cases they fill up the whole caliber of 
the auditory canal, and even project out of the meatus like 
a fungous growth. Again they can only be detected at 
the bottom of the ear by a thorough and careful examination 



47^ AURAL POLYPI. 

when they are found imbedded in pus and secretion, and 
scarcely as large as a hemp seed. When lying very deeply 
an aural polypus is always red and soft. It sometimes 
resembles a strawberry, since its roundish surface is com- 
pletely covered by little granular elevations. When a 
growth extends to the external meatus, it is covered by 
a rigid, non-secreting integument, so that at the first 
glance it may be mistaken for a part of the auricle, or 
for a button-shaped outgrowth. 

Aural polypi may originate in all the different parts and 
divisions of the ear. According to my experience, they 
most unfrequently arise from the external auditory canal, 
when they take their origin from the immediate vicinity of 
the membrana tympani. We may then see quite a number 
of them with independent roots around the membrane. 
Wilde and Toynbee have found on the contrary that they 
most frequently arise from the auditory canal. The latter 
named author has most frequently seen them on the posterior 
wall of the canal. {Clarke 1 of Boston, also states the most 
frequent point of origin of these growths to be the auditory 
canal; of thirteen cases reported by him, eleven arose from 
some part of the meatus. My experience indicates the 
cavity of the tympanum as the common point of origin of 
aural polypi. St. J. R.) 

If they arise from the surface of the membrana tympani, 
it is generally from the posterior and upper portion near its 
margin. I once found, on the dead body, in connection 
with a polypus of the external auditory canal, and one of 
the Eustachian tube, a third, which in accordance with its 
position and microscopic structure proved to be a polypose, 
degenerated membrana tympani. I have also, on the liv- 
ing subject, met with excrescences, the form and extraordi- 
nary sensitiveness of which led me to regard them as 
proliferations of the membrana tympani. 

1 Observations on the Nature and Treatment of Polypus of the Ear. Boston, 1867. 



AURAL POLYPI. 477 

Aural polypi most commonly arise from the mucous 
membrane of the cavity of the tympanum, and from the 
upper portion of the Eustachian tube. Very often, growths, 
which half fill the auditory canal, have their origin just 
behind the membrana tympani, partly in the mucous 
fold of the membrane itself. If polypi extend out of the 
cavity of the tympanum, through a hole in the membrana 
tympani, they make almost the same impression as if their 
origin was in the membrana tympani itself, and mistakes 
as to their point of origin may readily occur. 

I can show you a preparation where a growth, which 
during life, was considered to be a polypus of the auditory 
canal, on more exact examination on the dead body, was 
found to proceed from the hollow space belonging to the 
middle ear, which lies above the osseous part of the audi- 
tory passage. It then seemed as if it sprang from the 
integument of the upper part of the meatus. 

Developed granulations of connective tissue are often 
comprehended in the term aural polypi, and practically we 
can say nothing against such a view. 

Of the aural polypi which I have examined, only a few 
had hollow spaces on section; among these was the degene- 
rated membrana tympani above described. The cavities 
were filled with detritus, fat corpuscles, and granular bodies. 
The others were solid, principally consisting of connec- 
tive tissue, with a few fibrous filaments. They do not 
always possess ciliated epithelium, as has been asserted, 
but it may be sometimes distinguished in the various 
lamellae, in the deeper structure, when on the external sur- 
face none is detected. In large polypi, the part at the 
meatus is rigid, having a smooth whitish surface, and is 
covered by smooth epithelium, while on the under part, 
which is soft and red, there is cylindrical epithelium on 
its granular or lobular surface, and some ciliated structure. 



47§ AURAL POLYPI. 

The lamellated structure is best seen by examining the 
growth under water. 

As has been said, these growths generally occur as a 
result of a long-continued purulent process. An otorrhoea 
may be maintained for a long time by a polypus, since it 
will secrete pus very freely, and keep up the irritation in 
the morbid tissue beneath, while, if it were removed, the 
chronic inflammation would probably subside, and the 
part be covered by a new membrane. 

An otorrhoea, which we cannot check by local treatment 
and cleanliness, will be often found connected with excres- 
cences, which, be they never so small, are the only expla- 
nations of the continuation of a chronic inflammation of 
this kind. If you remove them, the inflammation imme- 
diately closes as if it were cut oflF. Blood is often mingled 
with the pus in varied proportion in such cases. 

Such growths may grow very rapidly, and to a great 
size. I saw a case in a young man whom I treated on 
account of an exacerbation of otitis interna with perfora- 
tion. I allowed him to go home after the subsidence of 
the acute symptoms. Six weeks after a polypus formed, 
reaching out to the meatus, and of which there was not 
the slightest trace when I last saw him. 

Treatment. — We may remove very small growths by 
means of repeated applications of nitrate of silver. We 
may cause larger ones to shrink away by pencilling them 
with acetic acid, with tincture of opium, with the infus. or 
tr. cantharides, with a strong solution of sulphate of zinc 
(40 to 60 grains to the ounce of water), or with creasote. 
Such procedures are slow, unsafe, and, when with creasote, 
very painful. In certain cases, powdered alum strewn 
upon the part, does very good service. Gruber advises 
the use of equal parts of alum and sulphate of zinc upon 
granulations. 



AURAL POLYPI. 479 

When it is possible, I would advise the resort to an 
operation, and, I do not know any better instrument for 
removing them than Wilde's 'polypus noose or snare, 
which I now present to you. 

This consists substantially of a steel shaft, bent at an 
angle at the middle. The lower end of the shaft is round, 
while the upper is of a quadrilateral shape, in order that a 
cross-piece may be moved upon it. A fine wire is made 
to run from this cross-piece, the length of the instrument, 
through rings at the side. The handle has a half ring for 
the thumb, by means of which the whole apparatus is 
held, while the cross-piece is drawn back with the index 
and ring-finger. 

The handle and cross-piece are made of German silver. 
Wilde recommends a steel wire, but I use one of silver, 
because it does not rust so easily. When we have ascer- 
tained, by means of a sound, the position and depth of the 
polypus, we make a noose of the wire, just large enough 
to encircle the base of it. We then pass the instrument 
in, and the noose about the tumor, and by means of the 
cross-piece draw the wire back, and thus cut through the 
polypus. The haemorrhage consequent on the excision is 
generally considerable. After the ear is syringed out, we 
examine it anew, and often find another polypus, which we 
should immediately attempt to remove. 

When these polypus growths extend very far out of the 
ear, the integument of the auditory canal is swollen and 
excoriated, so that in consequence of the increased narrow- 
ness and sensitiveness of the part we are not able to pass 
the noose to the bottom, and are obliged to remove the 
excrescences piece by piece. Since considerable haemor- 
rhage arises after thus cutting off a piece, the subsequent 
,' examination and reapplication of the instrument is impos- 
sible, and we are obliged to subject the patient to several 
sittings in order to remove the whole of the morbid growth. 



480 



AURAL POLYPI. 



We learn the value of Wilde's instrument in removing 
very small granulations which may rest on the membrana 
tympani itself, and which, on account of their smallness 
and deep situation, we can scarcely reach with any other 

Fig. 38. 



Wilde's polypus snare. 



instrument. In other methods of removal we run the 
danger of causing severe pain to the patient, and of 
injuring the membrana tympani, but with this noose intro- 
duced through the speculum, and illuminated by the con- 



AURAL POLYPI. 48 I 

cave mirror, it can be removed close to the base in a mo- 
ment of time. 

As I have said, I prefer this method of removal with 
Wilde's noose to any other, and in only one instance, 
where a long-existing, dense, and thick polypus reached 
out to the meatus auditorious externus, did it fail me. 
No wire could cut through such a hard body as this was. 
I could not bring scissors or knife to my assistance, and it 
seemed to me too formidable an operation to undertake to 
remove it with the polypus forceps or pincers. We can 
never tell beforehand where polypi of the ear have their 
origin, and in using the forceps we may remove a portion 
of the wall of the cavity of the tympanum, or of the 
membrana tympani. 

It may be that the use of this last-named instrument 
has taught many authors to consider the removal of aural 
polypi dangerous, and caused them to warn the profession 
from attempting the operation, for the pincette or forceps 
are almost generally used, and in many cases whatever 
comes in their grasp, be it polypus or not, is dragged out. 

As many polypi as I have removed, I have never seen 
other than favorable results. In one case there was a re- 
lief from a sensation of cerebral pressure immediately after 
the removal of the growth. Schwartze 1 saw hemiplegia 
with ptosis and imperfect anaesthesia of the same half of the 
body, disappear after the removal of aural polypi. Even 
in cases where there is caries of the petrous portion of the 
temporal bone, and the polypi are nothing less than pro- 
liferating fleshy growths, I have no hesitation in removing 
them in one way or the other. It is also true that such 
excrescences in many cases disappear of themselves, after 
a necrosed bone is removed from the ear, but that before 
the bone is healed, they spring up very rapidly after being 
removed. It is true, however, that we cannot always pro- 

1 Archiv fur Ohrenheilkunde, I, s. 147. 
6l 



482 AURAL POLYPI. 

tect the patient from a fatal result by such a removal, espe- 
cially if we operate too late. If the polypus be removed 
to a certain depth with a wire noose, the roots may be 
removed by cauterization with the nitrate of silver, after 
we have cleared the auditory canal of all secretion, and 
dried it by means of cotton introduced with a forceps, or 
the remainder may be brought to a gradual shrinking pro- 
cess by the use of strong astringents. 

We should never omit such an after treatment of po- 
lypous growths, or there will soon be a new formation in 
place of the old one. This is the more necessary when a 
portion remains in the cavity of the tympanum, in the 
depth of which there can be no thought of an operative 
expedient, or at least only to a very limited degree. If 
the different portions of the swollen tissue at last separate 
themselves through thorough cleanliness, and the use of 
astringents, we may remove one or the other of the excres- 
cences by means of the noose or caustic. I use a very 
fine point of nitrate of silver for cauterizing the middle 
ear by means of the caustic-holder here presented. 

Fig. 39. 




Caustic-holder. 



It would be very wrong to leave the patient to himself 
immediately on the removal of the polypus. The inflam- 
matory process giving origin to the growth, which is most 
frequently a purulent catarrh of the middle ear, should be 
thoroughly treated, and removed in the manner that has 
been previously described, otherwise our treatment will be 



AURAL POLYPI. 483 

only palliative, and sooner or later another proliferation 
of tissue will occur. On the other hand, it is surprising 
how much even old and severe cases may be improved by 
such a consecutive treatment, not only as to the anatomi- 
cal condition of the parts, but also as to the functions of 
the ear. 

It has been advised to remove the whole of such polypi 
by means of cauterization, especially with Vienna paste in 
the stick, or with chloride of zinc. I confess I do not 
consider the use of fluid caustics, whose effects we cannot 
limit, as appropriate for the interior of the ear, since injury 
may thus easily occur, and an unnecessary amount of pain 
is caused. Meniere 1 states that he has often observed that 
necrosis of the osseous meatus has occcurred when, in 
cauterizing aural polypi, the surrounding parts have not 
been sufficiently protected from the action of the caustics. 

I should still remark, that roundish polypoid growths 
are sometimes removed spontaneously, especially after the 
ear has been syringed. Very slight hemorrhage then occurs. 
Scbwartze 7, has lately described a case where, according to 
the statement of the patient, a larger polypus fell off of 
itself. (I am glad to state, that the experience of several 
physicians in New York, who see a great deal of diseases 
of the ear, seems to show that aural' polypi are becoming 
quite rare. This fact must depend upon the improved 
treatment of the original affection which causes them to 
occur. St. J. R.) 

Foreign Bodies in the Ear. 

More importance has been attached to this part of aural 
surgery than really belongs to it. Children sometimes 
place glass beads, cherry pits, peas, buttons, and the like, 

* Gazette med. de Paris, 1857, No. 50. 
2 Archiv fur Ohrenheilkunde, Bd. 11, s. 9. 



484 FOREIGN BODIES IN THE EAR. 

in the ear. Besides, insects sometimes creep into the ear 
of an adult, and disturb the patient very much. 

The presence of these bodies in the ear is generally less 
injurious than the attempts to remove them. We may 
take for a motto in this part of our subject, the old 
proverb, "Blind zeal only does harm" (Blinder Eifer 
schadet nur). 

We may accept it as a fact, that many bodies, especially 
those that are rounded off and have no sharp edges, as 
long as they have not been forcibly pressed into the ear, 
will fall out of themselves, or at least do no harm. The 
literature of the subject also shows that quite large foreign 
bodies — e. g., a molar tooth — have remained for years in 
the ear without doing any harm. Suppurative processes 
in the ear are indifferently regarded, or considered as a sort 
of noli me tangere, while a harmless bit of bread or paper, a 
grain of shot, or a pea, is followed up with unrelenting 
fury, as if its presence placed the life of the patient in 
immediate danger. 

Really we can but wonder how often energetic attempts 
at extraction are undertaken by physicians as well as 
laymen before the trouble is taken to ascertain if the 
patient be in the right, and a foreign body is actually in 
the auditory canal. There are some caustic descriptions 
of such attempts, and their consequences, in Wilde's 
Aural Surgery. 1 There have also been a large number of 
cases observed in ancient as well as modern times, where 
patients have died, not, as the histories generally read, 
from the presence of the foreign bodies, but from the 
attempts at extraction. In other cases great impairment 
of the general condition, not to speak of deafness, has 
resulted. 

I was once hurried out of bed by a servant girl, who, 
with a woful countenance, and tears in her eyes, told me 

1 Practical Observations on Aural Surgery. London, 1853, p. 178. 



CASES OF FOREIGN BODIES IN THE EAR. 485 

that an "Ohrenhollerer," the popular name in Franconia 
for earwig (Forficula auricular is), had crept into the ear, 
and that some persons had introduced a blade of straw in 
order to remove it. "Luckily" there lived a young sur- 
geon in the house, who was also called, and by means of a 
pair of forceps took part in the hunt. He assured her that 
the animal was removed, but as she had been attacked 
during the night with severe pain in the ear, she thought the 
insect must be still there. • I illuminated the ear by means of 
a concave mirror and study lamp, and found certainly no 
insect, but a very much reddened auditory canal, and in- 
tensely injected membrana tympani, naturally the conse- 
quence of the hunt which had taken place in the ear. 

A more serious case was the following : The lover of 
a young girl in the country, in sport one evening, placed 
in her ear a small piece of bread, which could not be 
removed. A surgeon, who was called in the night, 
attempted to remove the foreign body by means of a probe, 
forceps, and scissors, and he also injected the ear with cold 
water. These attempts to get possession of the piece of 
bread, renewed several times, were at last obliged to be given 
up, because considerable bleeding from the ear resulted, and 
the patient, who had borne up well till then, declared that 
she could endure the pain no longer. To remove the 
inflammation, cold water was applied to the ear for several 
hours. Some days after, I first saw the patient, and found 
a very severe and extensive inflammation of the auditory 
canal, it being very much sVollen. In spite of energetic 
antiphlogistic treatment, the inflammation did not subside, 
several subcutaneous abscesses appeared in the depth of 
the auditory canal, and the local and general symptoms 
became so threatening, that I was for some days very 
anxious for the life of the patient. 

The inflammation gradually, however, abated, and in 
about four weeks she was able to leave her room. I con- 



486 FOREIGN BODIES IN THE EAR. 

fess this was a little too much for a piece of bread. I 
would leave such a foreign body to itself, for I cannot see 
how its presence could do harm, and it would probably 
during the night or following day get out of itself. 

If an insect or other animal creeps into the ear, the 
simplest and best thing to do, is, to fill the ear with 
water. The animal being thus inconvenienced, will creep 
out of itself or be drowned and fall out. If a cigar happens 
to be at hand, a little tobacco smoke may be blown into 
the ear. A great surgeon of our day, Malgaigne, recom- 
mends catching an animal which has crept into the ear, 
with a camers-hair pencil dipped in glue, and Verdue advises 
that it be baited with a piece of golden apple. Hyrtl well 
remarks that such propositions are too ludicrous to be con- 
sidered by the surgeon. We can scarcely believe, however, 
what ridiculous and laughable expedients have been sug- 
gested for the removal of foreign bodies from the ear. 
Thus, the well known Itard recommends that seeds be 
left in the ear till they have sprouted, and that they then 
be removed by the sprouts. Bermond (1834), reported 
that he had removed a bean by placing a leech upon it. 
Rau y l from whom I take the last example, considers the 
proceeding as calling to mind the method of Arculanus 
(1493), who recommended that the head of a recently 
killed lizard be placed in the ear. Three hours after the 
insect would be found in the mouth of the lizard. 

A great number of forceps, nooses, perforators, etc., 
have been recommended for the" removal of foreign bodies 
from the ear. Some of them are of very complicated con- 
struction, and their number does not diminish even at this 
day. It is true, that there is considerable room between the 
figure of a bead, and the oval or ellipsoidal contour of the 
auditory canal, so that a small lever can be introduced under 
the offending body. In such cases, however, a properly 

i "Lehr Buch der Ohrenheilkunde." Berlin, 1856, p. 376. 



FOREIGN BODIES IN THE EAR. 487 

injected fluid will also collect behind the body, and wash it 
out, or dislodge it so that the removal can be completed 
with the angular forceps, or so that a thin and broad body 
can be introduced behind it, such as is found on the handle 
of a Daviel's spoon. 

If, however, there is no room between the walls of the 
auditory canal and the foreign body, we shall only incur 
the danger with any one of these instruments, of lacerat- 
ing the wall of the passage or of sinking the body still 
deeper, and of pressing it against the drum of the ear, 
whereby the condition of things will be made considerably 
worse. In some cases, a space may be made through 
which water may pass, by the use of a lever placed behind 
the foreign body. 

In the great majority of cases, injections of luke-warm 
water, properly made, to which a little soap may be added 
in order to lubricate the parts, will do more to remove 
such foreign bodies, than all direct attempts at their ex- 
traction. If the latter are attempted, the parts should be 
well illuminated, and perfect quiet of the patient be assured. 
During the syringing, the head should be so inclined as to 
favor the exit of the foreign body, and the auditory canal 
be straightened by traction on the auricle. Generally, a 
lateral position with the ear directed downwards, will be 
the best, but when the foreign body is firmly held in 
the depression, which the lower wall of the canal makes 
close to the drum, a recumbent position, with the head 
hanging over backwards, will most favor the exit of the 
body. When there is swelling of the integument about 
the body, I would apply a leech or two on the meatus. 

If a case came under my observation, where an impacted 
body produced such symptoms, that an energetic treatment 
for its removal was indicated, and delay as above recom- 
mended was not practicable, I would remove it by making 
an opening through the wall of the auditory canal, and 



488 FOREIGN BODIES IN THE EAR. 

seizing the body from behind. Paul of iEgina (1533), and 
the other ancient surgeons recommended in such circum- 
stances, in cases of necessity, to immediately make a 
crescent-shaped incision behind the ear; and, Hyrtl calls 
particular attention to this method, which has been aban- 
doned by Malgaigne, Rau, and others. I agree fully with 
the principle involved in this operation, although, I would 
not enter from behind, but from above, choosing another 
position for the incision, for various reasons. 

The posterior auricular artery runs immediately behind 
the auricle in the angle which it makes with the mastoid 
process; this artery is quite a large vessel, and this is the 
point indicated for an incision. In incising here, one 
could hardly avoid doing injury to the vessel. Further- 
more, we would be prevented from separating the concha, 
and the cartilaginous portion of the auditory canal, on 
account of the curvature or arching of the mastoid pro- 
cess, and we should not be able, therefore, with a curved 
instrument to go deeply enough. I have, however, satisfied 
myself on the dead body, that we can easily separate the 
auditory canal from the squamous portion of the temporal 
bone, and thus with a curved aneurism needle, reach the 
plane of the membrana tympani. This operation is doubly 
easy in children, where there is scarcely any bony canal, and 
where by the sinking in of the temporal bone, out of 
which the upper wall gradually forms itself, a very oblique 
plane is formed, which leads to the drum of the ear in a 
very obtuse angle. In children, in whom the cases most 
commonly occur, and where the foreign bodies sometimes 
are pushed in further, by the efforts of a teacher or others 
to remove them, we can get at the membrana tympani 
through the soft parts very easily. The operation would 
be far less formidable, and safer than the commonly 
attempted methods of extraction by means of instruments. 
Of course, such a procedure must be reserved for cases of 



FOREIGN BODIES IN THE EAR. 489 

the most pressing necessity. Once more, never forget to 
assure yourselves that the story of the patient is true; see 
if perhaps the auditory canal is not already free, and if the 
symptoms are not merely those resulting from previous 
attempts at extraction. 

Furthermore, do not attach more importance to foreign 
bodies in the ear than really belongs to them, and first 
attempt to remove them by the simple injection of water, 
with or without a preceding anti-phlogistic treatment. 
Our aged fellow-countryman, the accomplished city phy- 
sician in Nuremburg, says: "Chirurgus menti prius et 
oculo agat, quam manu armata," in German, "Der Arzt 
muss zuerst iiberlegen und untersuchen, bevor er operirt." 
The surgeon should consider a case very carefully with 
mind and eye, before he resolves upon an operation. 

(I once removed a button from the ear of a child, 
which had been forced through the drum, in the attempts 
to remove it, by the continuous application of poultices, 
which brought the foreign body to the meatus. St. J. R.) 

In one case, where a little brass ball of three and a half 
mm. in diameter had passed through the membrana tym- 
pani into the cavity of the tympanum, and I had unsuc- 
cessfully attempted to force it into the auditory canal by 
driving in air and water through the catheter, I at last hit 
upon the idea of snaring it with Wilde's polypus forceps. 
In this way I removed the body, which was in plain sight, 
without any pain. I would suggest the use of the same 
instrument in similar cases. 

If we have seen that more importance is sometimes 
ascribed to'foreign bodies in the ear than is their due, I 
would now like to call your attention to a class of cases 
which demand a very careful regard. I would ask you to look 
to the ear for the explanation of some cases of disturbances 
of the system, which do not seem to originate in the ear 
since the effects of irritation of the auditory canal, especially 
62 



49° REFLEX NERVOUS PHENOMENA. 

those from the long-continued presence of foreign bodies, 
often locate themselves in other nerve channels, and are 
capable of causing a permanent morbid condition of general 
excitement. You all very well know, that contact with the 
auditory canal often produces tickling in the throat, and 
that the introduction of an ear speculum causes many 
persons to cough. You also know that these reflex nervous 
phenomena, must depend on the supply of nerve material 
from the pneumo-gastric to the epidermis of the auditory 
canal. We have also seen that some persons experience 
sensations of dizziness when the ear is syringed, and that 
masses of cerumen pressing on the ear may also excite 
such symptoms. Such patients are considered as suffering 
from cerebral disease. Pechlin has observed a case in 
which touching the external auditory canal excited severe 
vomiting; and Arnold tells of a girl who suffered from a 
severe cough and expectoration, which recurred very often, 
and thereby visibly emaciated her. On closer examination 
she confessed that there was a bean in each ear, which had 
been placed there in playing some time before. The re- 
moval of these beans was accompanied by severe cough- 
ing, vomiting and sneezing. The symptoms then ceased, 
and the girl fully recovered. 1 

In a case observed by Toynbee, the patient suffered from 
a severe cough, which was not alleviated by treatment, but 
which ceased as soon as a piece of necrosed bone was 
removed from the auditory canal. Boyer relates a case 
from the practice of Fabricius Hildanus, where a girl who 
suffered from epilepsy, atrophy of one arm, and anesthe- 
sia of an entire half of the body, was cured of all these 
symptoms when she was eighteen years of age, by the 
removal of a glass ball from the ear, which she had placed 
there eight years before. 2 The ear was never previously 

i Romberg's Lehbuch der Nerven Krankheiten. Berlin, 1851, vol. II, p. 130. 
2 Boyer, Chiriurgische Krankheiten. Wurzburg, 1821, B. VI, s. 10. 



HYSTERICAL AURAL DISEASE. 49 I 

examined, because pain was never complained of in this 
part. Wilde relates a case of epilepsy and deafness which, 
according to the view of the observer, arose from the pre- 
sence of a foreign body in the ear, and was relieved by its 
removal. It is well known that epilepsy and other 
nervous diseases may occur as reflex symptoms, from 
the pathological irritation of peripheral nerves, as well as 
from the irritation of the nerve center itself. 

When we consider these facts, and how abundantly the 
ear is supplied with sensory branches from the trigeminus 
and pneumo-gastric, in connection with the above experi- 
ence, we should not always assign other causes for extra- 
ordinary symptoms, until we ascertain if there be not a 
possibility of their arising from the ear. In the course of 
our observations we have often spoken of constitutional 
disturbances which are more or less distinctly connected 
with aural affections, and hence I do not consider myself 
presumptuous when I hope there is a day coming when, in 
a considerable number of diseases, intelligent surgeons will 
consider the ear, as well as the pupil, as a part to be always 
examined. 

(In addition to the very interesting remarks of the 
author on this subject, I would like to add, that I have 
seen four cases of monomania on the subject of foreign 
bodies in the ear. While surgeon at the Eye and Ear In- 
firmary of this city, two cases presented themselves to me 
where the patients, both of whom were females, imagined 
that there was a pin in the auditory canal. No amount of 
reasoning could convince these patients that no pin was 
there. My friend, Dr. C. E. Hackley, suggested that a 
pin be placed in the water, which was done, and, after 
syringing for some time, we attempted to convince one 
of the patients that this pin was the one complained 
of. She was satisfied for a few moments, but soon 
found that there was another there. In a third case, the 



492 HYSTERICAL AURAL DISEASE. 

mother of the patient gravely stated, and the child con- 
firmed her story, that large pieces of anthracite coal were 
being excreted from the auditory canal. This case oc- 
curred at my clinic in the University Medical College. 
The patient brought a handkerchief full of coal which had 
been passed from the ear. The fourth case was that of a 
barber, who came twice to my office, and who was at each 
time quite offended because I could not find the foreign 
body which he stated was in his ear. These cases may 
perhaps be classified under the head of hysterical affections 
of the ear. St. J. R.) 



LECTURE XXVIII. 



NERVOUS DEAFNESS. 



Anatomy of the internal ear; nervous deafness; want of exact 
anatomical and clinical proofs of its existence ; a case of 
sudden deafness occurring in an artillerist; disease of the 
semi-circular canals , with cerebral symptoms (Meniere); 
secondary affections of the labyrinth very common; Helm- 
holtzs theory y and partial paralysis of the organs of Corti; 
deafness in intra-cranial disease {aneurism of the basilar 
artery , epidemic cerebro- spinal meningitis ;) diagnosis; general 
remarks on the relative infrequency of primary affections of 
the labyrinth. 

Gentlemen: We now turn to the most deeply situ- 
ated part of the ear, the so-called internal ear, and its 
diseases. I must refer you to the hand-books of descrip- 
tive and microscopic anatomy, for the finer details of the 
structure of this part. We, in our anatomical studies, 
have only a practical object in view. We must, therefore, 
be content with general descriptions. We are less 
justified in going into detail, from the fact that new 
investigations are making considerable changes and 
amplifications in our knowledge of the anatomy of the 
internal ear. 

Apart from the auditory nerve — the sensory nerve of the 
auditory apparatus — we divide the internal ear into two 



494 ANATOMY OF INTERNAL EAR. 

parts, the membranous and osseous labyrinths. The lat- 
ter surrounds the former. 

The membranous labyrinth consists of cavities, tubes, 
and vesicles. These communicate with each other, and 
are filled by a thin, watery fluid, the so-called fluid of the 
labyrinth. Their purpose is to carry the variously formed 
terminal expansions of the auditory nerve to various 
points. These terminal expansions of the nerve are 
everywhere connected to a peculiar assisting apparatus, 
which is in part elastic, and in part rigid, and which, under 
the influence of external vibrations carried from the stapes 
to the fluid of the labyrinth, may also be set in vibration, 
in order to shake and excite the nerve fibers. Of especial 
importance, in this respect, are the auditory tufts (Hor- 
haare), discovered by Max Scbultze in the ampulla, and 
that peculiar structure of the membranous spiral plate of 
the cochlea, which, from their discoverer, are called the 
organs of Corti. 

We may regard the vestibule, with its two saccules, as 
the anatomical middle point of the whole labyrinth. 
From the larger, the sacculus b erne lip ticus, the three con- 
volutions pass out; the smaller, the sacculus hemispbaricus, 
according to recent investigations, is the cul de sac begin- 
ning of the membranous cochlear canal. 

Voltolini questions the existence of the round saccule, while Ru- 
dinger, Hensen^ and Reichert, maintain that it is to be found. 

The cochlea, with its membranous spiral plate, and very 
complicated structure, appears, in a physiological respect, 
to be the most important part of the labyrinth, and of the 
whole auditory apparatus. Towards the cavity of the 
tympanum, as is well known, the vestibule is closed by 
the base of the stapes and its enveloping membrane, but 
the cochlea is closed by the membrane of the fenestra 
rotunda. 



ANATOMY OF INTERNAL EAR. 495 

The auditory nerve is divided into two chief branches. 
The anterior or cochlear nerve passes to the cochlea and 
its vestibular attachment, the round saccule; the posterior 
or vestibular nerve, proceeds to the elliptical saccule and 
the ampulla of the semi-circular canals. No nerves 
ramify on the membranous semi-circular canals, except 
those on their dilated or enlarged beginnings, or the am- 
pullae. 

Towards the meatus audit orius internus the two labyrinth 
cavities, the vestibule and cochlea, have a number of 
cribriform perforated places in their walls (called macula 
cribrosa in the vestibule, and tr actus spiralis fo amnio sus in 
the cochlea). Through these perforations the tuft-like 
radiations of the auditory nerve pass to the different 
parts. 

The internal auditory canal, in which the facial nerve 
runs along with the auditory, must be considered as a 
lateral canal of the skull, since it is covered by a continu- 
ation of the meninges, and is filled by the cerebro-spinal 
fluid. 

Hyrtl states that he has found fluid which he had injected into the 
sub-arachnoid space of monkeys in the vestibule. He did not make 
the experiments on the human subject. "It is not impossible that 
the perilymph of the vestibule is cerebro-spinal fluid." 

Nervous deafness. — A Distinguished opthalmologist 
once described amaurosis, or nervous blindness, as that affec- 
tion of the eye in which the patient sees nothing, and the 
physician also nothing. Since the discovery of the opthal- 
moscope this definition has lost its point, for with its aid we 
can recognize many different changes in structure in cases 
of amaurosis. Yet, we may avail ourselves of it for nervous 
deafness, since this is that disease of the ear in which the 
patient does not hear, and the physician does not see. 

We must decide that a patient is affected with nervous 






496 NERVOUS DEAFNESS. 

deafness when we can find no change in the material struc- 
ture of the auditory apparatus, from which the diminu- 
tion or loss of the power of hearing can be deduced. Of 
course such a diagnosis requires a very exact knowledge of 
the parts, and a thorough capability of observing slight 
deviations from the normal; and nowhere is the degree of 
advancement of the physician, and the stage of develop- 
ment of science, better shown than in the diagnosis of 
nervous diseases. 

With every increase of our knowledge of the morbid 
processes taking place this side of the labyrinth, and with 
every improvement of our method of examination, the 
field of nervous affections of the ear becomes smaller. 

On the other hand the diagnosis "nervous deafness" 
will be the oftener made, the less the surgeon is able to 
distinguish the different affections, the less he understands 
how to examine the affected portions, and the less know- 
ledge he has of the pathological changes of the external 
and internal ear. 

Examinations of other fields of science, as well as the 
history of medicine, teach us, that in proportion to the 
improvement of the objective modes of examination of 
nervous complaints, and the progress of science, and the 
influence of pathological anatomy, the diagnosis "nervous" 
becomes, to a certain degree, a chance hit, a declaration of 
not knowing and not finding, and that it is only a common 
one for those who use it willingly. 

I will call only one department of disease to your recol- 
lection, in which we were formerly contented with the fre- 
quent diagnosis "nervous affection:" — affections of the 
female genital system. Now, these are found to depend 
very often on very material changes in the uterus and 
ovaries, and we are able to .make a more favorable prog- 
nosis in affections, when properly treated, which were 
formerly regarded as incurable. 



NERVOUS DEAFNESS. 497 

Let us confess, gentlemen, that we are apt to call those 
affections "nervous," which we can neither diagnosticate 
nor improve by treatment. 

How much reflex influence the degree of advancement 
of the physician has in the frequent acceptation of the 
term — nervous deafness — may be seen, perhaps, by notic- 
ing the different phases of development in the writings of 
one of the oldest aural surgeons of the present day, Wil- 
helm Kramer. This author says, that while formerly he 
considered nervous affections to be the most common of 
all of the ear, almost exceeding fifty per cent of all the 
cases, now, with the advance in pathological anatomy, 
especially in the study of exudations, he has reduced their 
frequency to a minimum — four in a thousand. 1 

Let us see, now, what may be said from the stand-point 
of anatomical and clinical facts, in relation to nervous 
deafness. Its anatomical substratum must necessarily be 
sought for in the labyrinth — in the auditory nerve and 
its source of origin, and finally in the brain, whose dis- 
turbances of circulation will always declare themselves in 
the internal ear; since the vessel carrying blood to the 
labyrinth is a cerebral artery, and the veins, vena auditorix 
intern*, enter into the venous sinuses of the dura mater. 

Rudolph Wagner says: "One of the most humiliating 
tests of the incompleteness of our knowledge of the func- 
tions of the parts of the brain is this — that the central 
organ of hearing is entirely unknown, while we certainly 
know that for sight. I think it probable that it is to be 
sought for in the medulla oblongata spinalis. 4 

Very few morbid changes have as yet been observed in 
the labyrinth, which fact is due to the unexplored condi- 
tion of this branch of science; and we are not certain if 

i See New Sydenham Translation of Ohrenheilkunde der Gegenwart. "Aural Surgery 
of the Present Day." Berlin, 1861, s. 39. 

2 Zeitschrift fur ration. Medezin. 1861, B. 10, s. 277. 

63 



49§ DISEASES OF LABYRINTH. 

the processes which have taken place in the middle ear are 
primary, and those of the internal ear only secondary. 
And, furthermore, some of the so-called changes may be 
normal conditions; such as the greater or less quantities of 
otoliths, and the presence of the often spoken of black 
pigment, which, in almost every healthy ear, may be found 
in different parts of the covering of the labyrinth. 1 Many 
alterations may depend on post mortem appearances, which 
show themselves very quickly in these parts, and make the 
decision as to the signification of the appearance difficult. 

Toynbee? who has made the greater number of sections 
of ears, gives, as among the appearances of the labyrinth, 
the following: extravasations, exostoses, thickening and 
atrophy of the integuments, insufficiency of the semi- 
circular canals, hypertrophy of the cochlearis muscle. 
However, his descriptions are extremely short and frag- 
mentary, and he does not appear to attach much import- 
ance to "nervous deafness" in his text-book. 

Voltolini speaks much more of the diseases of the in- 
ternal ear. In almost every temporal bone of deaf per- 
sons which he examined, he found morbid changes in these 
parts, and therefore he, like Kramer — except that his 
opinions are based on anatomical grounds — considered 
nervous deafness the most common of the diseases of the 
ear. 3 

He found thickening of the membranous portions, cal- 
careous formations, and at one time a fibro-muscular 
tumor in the cupola of the cochlea, absence and excess of 
otoliths, collections of pigment, amyloid degeneration of 
the auditory nerve, and once a sarcoma of the nerve. 
Fortified by these appearances, and the very frequent 
changes on the fenestra rotunda and ovalis, Voltolini asserts 

i Vide Kolliker's Geweblehre. 1852. § 234, and $ 235. 

2. Descriptive Catalogue of Preparations. London, 1857, p. 75, et seq. 

I Virchow's Archiv, Heft I and 2. 



NERVOUS DEAFNESS. 499 

that the greater number of ear patients suffer from 
(C nervous deafness." 

Up to this time, none of these anatomical conditions 
have been observed on subjects whose cases were studied 
during life; so that clinical confirmation of the alleged 
frequency of nervous deafness is wanting. We are as yet 
chiefly limited to those cases where the probabilities are in 
favor of the nervous or cerebral nature of the affection, 
but where, again, the pathological evidence is wanting. 

According to Arth. BoUcherf concretions of phosphate of lime, 
occur on the covering of the porus acusticus internus^ most frequently 
on its base, and in old persons. We may then believe that the hearing 
becomes affected, at least when the collection is very great, and when 
it seizes upon the neurilemma. The peculiar structure or formation, 
occurring in the membranous semi-circular canals should be also men- 
tioned. It has been observed by Lucae, Politzer^ and Voltolini, and 
in healthy ears. We can not, as yet, give any definite idea as to its 
nature or importance to the organ of hearing. 2. 

Thus it is often said by patients, that after somewhat 
large doses of quinine, they have suddenly been attacked 
by a violent singing in the ear, accompanied by consider- 
able difficulty in hearing, an affection, which generally — 
although not always — entirely disappeared after a while. 
These phenomena appear generally, accompanied by other 
symptoms of poisoning or narcotization. They must, 
therefore, no doubt, be attributed to the effect of quinine 
upon the brain, or upon the vascular system. In this 
connection, also belongs that temporary deafness, which 
Von Scanzoni several times observed, after the application of 
of leeches to the vagina, usually connected with a general 
vascular excitement, and with the eruption of Urticaria over 
the whole body. Hysterical and chlorotic patients often 

i Virchow's Archiv, 1857, xii, s. 104. 
2 L. C, xxv. B. 



500 CASE OF NERVOUS DEAFNESS. 

experience peculiar vacillations in the power of hearing, 
which together with the negative appearances in the ear are 
in such singular sympathy with the general health, and the 
sexual functions, that they can only be denominated 
"nervous" phenomena. As in fainting, a transient sing- 
ing in the ear, together with difficulty in hearing, appears, 
so also is it the case with the longer existing anaemia of the 
brain, after a great loss of blood, or after some debili- 
tating diseases. To this may be added, in part at least, 
that impairment of hearing, with negative objective symp- 
toms, which is observable in people suffering from typhoid 
fever, a difficulty which generally disappears of itself in 
convalescence, with the improvement of the general health, 
or under an invigorating treatment. 

On the other hand, hyperemia of the structures of the 
labyrinth, with serous infiltration or ecchymosis may occur 
in continued fever, just as in acute purulent catarrh of the 
cavity of the tympanum. 

As is well known, severe concussions, or a fall on the head not 
unfrequently excite "nervous" deafness. Of the former class, I am 
able to relate to you, among other instances, a very striking one 
from my own experience. In the summer of 1858, an artillerist, 
Martin Baumann, 1 from Ansbach, 21 years old, was brought to me 
by the military surgeons Drs. Rast and Hausner. He himself, a 
strong, and as yet, always healthy man, states that he received in his 
ninth year, a blow on the ear from his father, in consequence of 
which he heard nothing in that ear for eight days. Whether he had 
any suffering with it, or on which ear he received the boxing, he 
cannot say. But he asserts quite confidently that he was able to 
hear perfectly well after that, until within two days. He states, 
that two days before, during artillery drill, he was connected with the 
service of a six-pounder gun ; and that he stood during the firing 
about two feet from the muzzle, his face parallel with the caliber of 
the gun. The first six shots, which followed each other at intervals 

* 1 have given the patient's name for the benefit of any surgeon under whose observation 
he may come. 



CASE OF NERVOUS DEAFNESS. 5OI 

of about ten minutes, excited a strong and unpleasant sensation of 
concussion. At the seventh shot, he felt an extremely violent pain 
in both ears, "as if a javelin was stuck through his head." From 
this moment he was deaf. This violent pain lasted about two hours. 
After that he experienced only a violent singing noise, together with 
a dead feeling in his head. The patient, who spoke extremely loud, 
understood only when spoken to slowly and distinctly through an ear- 
trumpet ; he did not hear a loud ticking clock, on the mastoid pro- 
cess, but only on the frontal bone ; and then he stated that he did 
not hear, he only felt a gentle concussion. 

In his organ of hearing, there seemed to be nothing out of order, 
excepting a slightly elongated red spot in the back half of the right 
membrana tympani, behind the middle of the malleus. This spot, 
which was a slight linear rupture, or small extravasation, rapidly grew 
paler, and continually smaller, and after two weeks it was scarcely 
discernible. Air blown in by a catheter entered easily and clearly 
from both sides, without any further phenomenon. With the exception 
of a dull feeling in the head, the patient was perfectly well. He had 
a good appetite, and all his functions were normal. His treatment in 
the military hospital consisted at first of calomel and jalap in aperient 
doses, simultaneously with cuppings on the neck ; afterwards, inunc- 
tion of tartarized antimony ointment behind the ears. The condition 
remained steadily the same, except that the patient gradually talked 
less boisterously. Twelve days after the accident, I commenced a 
treatment by faradization of the ears, first with a quite weak and 
brief current, slowly increasing its strength and the duration of the 
sittings. The negative pole was held in the entrance to the ear, 
which was filled with water, the positive pole rested on the moistened 
mastoid process, and afterwards on the neck also. After the treatment 
the tinnitus was a little stronger for a time. A violent pain in the ear 
accompanied stronger currents, and there was also some injection of the 
malleus. This electric treatment was continued daily for six weeks, 
with slight interruptions, without any change of the condition. The 
patient felt well before and after, except the continued dead feeling 
in the head. Malingering, which must be guarded against among 
soldiers, was not to be thought of, judging from his whole conduct. 
Moreover, during the whole time of his treatment, he was continually 
watched in the military hospital; and also, after he had been dis- 
missed at his home, where he followed his trade as a glove-maker. 



502 NERVOUS DEAFNESS. 

A report was made at the year's end, that his deafness continued 
unchanged, although it became soon less apparent, as the very intelli- 
gent patient quickly accustomed himself to observing the motions of 
the mouths of speakers. 

I believe, that this case can scarcely be explained in any- 
other way, than by the supposition that the violent explo- 
sive concussion, in this, perhaps, peculiarly predisposed 
person, produced a paralysis of the acoustic expansion, 
either directly (as sometimes the destruction of the optic 
functions is reported by a sudden excessive dazzling), or 
indirectly in consequence of haemorrhage in the labyrinth. 

If deafness occur after a fall on the head, it may often 
connect itself with changes in the brain, or with a fracture 
of the base of the skull, which, as you know, exends fre- 
quently through the temporal bone. For instance, there 
lives here a whitewasher, an extremely jovial fellow, who 
many years ago fell from a church steeple, which he was 
about to whitewash. He lay for a time in the Julius 
Hospital, in consequence of a fracture of the skull ; 
and since this accident, is so stone-deaf, that he assured 
me, that for the sake of trial, he had placed himself near 
a cannon being discharged, and that he had certainly/^// 
a concussion in his head and feet, but that he had heard 
nothing of the report. Such cases of absolute want of 
appreciation of sound are extremely rare, for even deaf 
and dumb people frequently appreciate a loud noise, for 
instance, the report of a percussion cap, or the ringing of a 
bell near the head. 

One of the most valuable contributions to the science of 
nervous deafness, we owe to late French investigators, 
especially to the late Dr. P. Meniere, of the Paris Deaf 
and Dumb Institute, who was altogether one of the most 
meritorious workers in the province of aural surgery. 



MENIERE S CASES. 503 

Meniere, in the year 1861, drew attention to a series of most 
remarkable cases, which appeared in the form of an apo- 
plectic congestion of the brain, with sudden vertigo, vom- 
iting, great singing in the ears, and a fainting condition, 
and which frequently left behind a certain impediment in 
motion, a continuing unsteadiness in standing and walking, 
and thus gave the surgeon from the beginning an impres- 
sion of a congestive affection of the brain ; but the con- 
stant recurrence of all these disturbances, and the fact that 
there generally was a very remarkable difficulty in hearing, 
for which no assignable change in the ear could be found, 
decidedly proved that there was an affection of the internal 
part of the organ. 

As if it were known to him that only a short period remained to him, 
in which to make known his observations, Meneire published them 
in rapid succession, in the Gazette Medicate de Paris, in 1861. 

The affection of the hearing proved itself to Meniere, 
despite all local and general methods of treatment, to be 
incurable; while the constitutional disturbances, which 
appeared so threatening, disappeared gradually, and the 
patients afterwards enjoyed complete health. Meniere, as 
a warrant for the presentation of this new form of disease, 
communicates a considerable series of histories of patients, 
and condenses his experiences in the following propo- 
sitions: 

1. A hitherto entirely sound organ of hearing may 
suddenly become the seat of functional disturbance, which 
consists in a humming in the ears of very varied nature, 
now continuous, again intermittent, to which is soon 
united a decline in facility of hearing of various degrees. 

2. These functional disturbances have their seat in the 
inner part of the auricular apparatus, and have the power 
of exciting apparent cerebral attacks, such as vertigo, 



504 Meniere's cases. 









stupefaction, unsteady motion, whirling motion, and sud- 
den falling down. They are also accompanied by inclina- 
tion to vomit, actual vomiting, and by a sort of fainting 
condition. 

3. These attacks, which occur after complete intermis- 
sions, are always followed by a greater or less degree of 
difficulty of hearing, and more frequently the power of 
hearing becomes suddenly completely annihilated. 

4. It is most probable that the material change which lies 
at the foundation of these disturbances has its seat in the 
semi-circular canals. 

This conjectural view that the seat of the disease was the 
semi-circular canals, Meniere supported partly by a similar 
case, on which a post mortem was had, partly by certain 
physiological experiments, The first is a case of a young 
girl, who in a night journey on the imperial of a diligence 
during her menstrual period, caught a severe cold, became 
suddenly completely deaf, experienced at the same time a 
continuous vertigo, vomited at each attempt to move, and 
on the fifth day died of the disease. The brain and spinal 
cord were entirely sound, and the ear showed no patho- 
logical change whatever, except in the semi-circular canals, 
which were filled with a red, plastic lymph, a sort of 
bloody exudation, of which scarcely any traces showed 
itself in the vestibule, and none in the cochlea. The 
physiological experiments, which must be here mentioned, 
are those of Flourens, who, as is known, after the removal 
of the semi-circular canal, in doves and rabbits, noticed 
different kinds of staggering movements, unsteadiness in 
walking and standing, with evident loss of equilibrium, 
and frequent tumbling down. 

An experiment of Signol and Vulpian, recently laid be- 
fore the society of Biology, is of great importance to this 
topic. [Brown Sequard 1 considered the observation of 

1 Gazette Hebdomadaire, 18 61, No. 4, p. 56. 



DISEASES OF INTERNAL EAR. 505 

Flourens as the result of the stretching of the auditory- 
nerve occurring in the experiment, since he saw the lateral 
rolling movements when the acoustic nerve of animals was 
traumatically irritated. However, Flourens could pro- 
duce no disturbances in motion by destroying the expan- 
sion of the nerve in the cochlea and vestibule, although 
the auditory nerve must have been then more stretched 
than in opening the semi-circular canals.) 

Signol and Vulpian observed a rooster, who, after a 
combat with his antagonist, presented precisely the same 
disturbances of equilibrium, and other manifestations in 
movement and rest, with those Flourens noticed after the 
injury of the semi-circular canals, and similar to those 
which Meniere reported in the above named cases. At 
the post mortem section every abnormity of the brain and 
its integument was wanting; on the contrary, there was a 
partial necrosis of the temporal bones, by which a greater 
part of the inner and middle ear of one side, as also the 
semi-circular canals, were for the most part destroyed. 
This case seems to speak, to a certain degree, for the cor- 
rectness of Flourens discovery, and serves, at all events, 
as authority for the assertion that diseases of the inner 
part of the ear are calculated to call forth identically the 
same results as the direct experimental injuries of this 
organ. 

Politzer 1 has recently reported an extremely instructive 
case. In consequence of a fall on the back of the head a 
fissured fracture occurred, which was continued on both 
sides through the petrous portion of the temporal bone. 
The immediate consequence, apart from a loss of con- 
sciousness of some hours, was complete deafness, with 
severe tinnitus, vertigo, and an uncertain, staggering gait. 
In the seventh week after the fall, acute suppurative basi- 
lar meningitis occurred, which, as the post mortem showed, 

1 Archiv fur Ohrenheilkunde, II, 2, s. 88. 

64 



506 DISEASES OF THE LABYRINTH. 

was caused by an extravasation from the left vestibule, 
which degenerated into pus. Hemorrhage into the vesti- 
bule in consequence of a fracture of the temporal bone, 
thus produced the symptoms detailed by Meniere. 

These communications are extremely worthy of notice, 
and should incite us to exact observations and experiments 
in this direction. The subject, nevertheless, may in no 
manner be considered as concluded. Manifold demon- 
strative dissections, and various corroborations of the 
facts are necessary before this may be said to be true. I 
myself remember, in my somewhat extensive practice, only 
a few cases which were analogous to that of Meniere, 
although here also certain symptoms were not to be re- 
jected, which implied a catarrhal process in the tympanum. 

In addition, we must remember, as has been already 
said, that all the symptoms detailed as pathognomonic 
may arise from various diseases of the ear — especially 
from the stoppage of the meatus by ear-wax or other 
material; from acute and sub-acute catarrh, and puru- 
lent processes in the cavity of the tympanum. We have 
seen that when these conditions cause vertigo and heavi- 
ness of the head, we must consider them as symptoms of 
abnormal pressure, made upon the drum, and therewith 
upon the ossicula, or upon the last articulation of the lat- 
ter, the stapes, and its fenestra. 

As we have seen, this pressure may be caused by a col- 
lection in the auditory canal, or in the cavity of the tym- 
panum, or by a permanent closure of the tube, and by the 
one-sided pressure thus exerted upon the membrana tym- 
pani. 

The increase of pressure, which was produced in a 
peripheral manner, and transferred from the stapes to 
the vestibulum, must necessarily place the semi-circular 
canals in an abnormal state of pathological irritation, 
and this condition might be designated as the same with ! 



DISEASES OF THE LABYRINTH. 507 

all these different forms of disease of the ear which are 
followed by vertigo; and perhaps it is of importance only 
for the extent of the appearances, and their further results, 
whether the irritation is one transferred from the peri- 
phery, or one that arises mainly in this division of the laby- 
rinth itself. In any event we must, for the present, be on 
our guard not to infer from similar instances that there is 
a primary affection of the semi-circular canals, or of the 
nervous apparatus. We should be extremely cautious in 
the diagnosis, if a little time before the sudden diminu- 
tion in the hearing power there were some symptoms of 
an aural affection, and also in cases that do not come 
under observation until some time after the apoplectiform 
deafness. Catarrhal processes of the tympanum sometimes 
localize themselves upon the wall of the labyrinth and the 
two fenestra, and a high degree of deafness appears with 
manifest symptoms of irritation of the inner part of the 
ear; while, on the other hand, the changes on the tym- 
panum are little manifested, and the remaining inferences 
which result from the condition of the mucous membrane 
of the throat, and the use of the catheter, frequently exist 
only in the beginning of the affection. 

I fully agree with Politzer, when he, in the course of an 
excellent analysis of the above described case, says: 
"Sometimes we are able to exclude any affection of the 
cavity of the tympanum, and diagnosticate one of the 
labyrinth. These are cases where the classes of symptoms 
detailed by Meniere, appear without previous ones, where 
they are very severe, and when the surgeon is able to 
examine the ear shortly after the attack. If, for instance, 
a person who has formerly heard well, becomes suddenly 
deaf, or hard of hearing, with the symptoms of an apo- 
plectic attack, and there is at the same time an uncertain 
and staggering gait, but there are no symptoms of paraly- 
sis in other nerve tracts, and if the examination shows a 



508 INABILITY TO HEAR CERTAIN TONES. 

normal membrana tympani, and perfectly permeable Eus- 
tachian tube, we may believe with great probability that 
there is an affection of the labyrinth. 

An affection of the cavity of the tympanum which sud- 
denly appears, with great impairment of hearing, and the 
above described very marked symptoms, is characterized 
by a speedy and abundant plastic or muco-purulent exuda- 
tion. Perceptible changes on the membrana tympani, and 
in the permeability of the tube, will then exist. Some 
time after the attack the diagnosis will be very difficult, 
since the products of the affection in the cavity of the 
tympanum, may disappear without leaving any anomaly 
on the drum or in the tube, and the very great impair- 
ment of function may be caused by an anchylosis of the 
ossicula auditus" 

That diseases of the middle ear often show themselves 
in a secondary manner on the labyrinth, we noticed before 
where we found that in every case of catarrh of the Eus- 
tachian tube — in consequence of one-sided atmospheric 
pressure, which weighed upon the membrana tympani — 
that the stapes is pushed further inward, and thus the fluid 
of the labyrinth is exposed to an increased pressure, which 
condition, if somewhat longer continued, will leave behind 
it lasting disturbances in the nutritive supply of the ear. 

Besides, we may believe, in all probability, that in a 
case of deafness of long standing, as, for example, from 
complete immobility of the ossicula, or calcification of the 
fenestra rotunda, that an atrophy of the acoustic expan- 
sion, with retrogressive metamorphosis of the fatty or 
colloid degeneration may occur as a consequence of the 
deficient specific excitation of the nerve. 

Deafness to certain tones. — This may be the proper 
place to mention a class of anomalies of audition which, 



HELMHOLTz's THEORY. 509 

up to this time, because resisting all explanation, have 
been considered merely as curious facts. There are people 
who, although they have an extremely acute and good 
hearing power, have never in all their lives heard the 
chirping of a cricket. This is said to be the highest tone 
that we know. 

It more frequently occurs, that suddenly, after some 
kind of an impression, most frequently after a violent 
concussion of the ear, from a shrill whistle, or an explosion 
near the ear, that either a whole class of tones, the highest 
or lowest, are not perceived, or that certain tones become 
false, that is, they are heard a third or an octave too high. 

Helmholtz believes that the acoustic expansion in the ves- 
tibule, and in the ampullae, serves for the perception of the 
non-periodical or irregular vibrations, that is, for ordinary 
sounds, but that Cortis fibers in the cochlea are designed 
for the perception of the periodical movements of the air, 
that is, for the musical tones. According to Helmboltz> 
the tuning (Stimmung) of the latter is different, and cor- 
responds to the regular gradation of the musical scale. 
The perception of different hights of tone is therefore a 
perception or sensation in different nerve filaments. In 
this view, the different quality of the auditory sensations 
or perceptions as to hight of tone and sound color (Klang 
farbe), must be referred to the variety of the nerve fibers 
which is excited. 1 

This extremely ingenious theory may sufficiently explain 
the above mentioned clinical observations. 

For a very masterly analytical observation of a case of "partial 
paralysis of the organs of Corti, we may thank A. Magnus. 7 - This 
author, at the same time, hit upon the ingenious idea of using a 
hearing tube in which several of Helmholtz* s resonators were inserted, 

1 Die Lehre von hen Tonempfindungen, Braunschweig, 1863, s. 219. 
a A. F. O., II, s. 268. 



5IO DEAFNESS FROM INTRA-CRANIAL DISEASE. 

for the relief of this affection. These were to be those adapted for 
the missing tones. 

In a case of deafness for bass notes, for example, we 
may believe that the fibers of Corti y set in vibration by the 
deep tones, can not perform their functions. The false 
sound of certain tones may be referred to the alteration in 
certain fibers, by swelling or partial pressure, and so on. 

Deafness from intra-cranial disease. — In discussing 
those forms of nervous deafness that are produced 
by certain intra-cranial processes, it becomes our task 
to speak of all pathological conditions that may exert 
pressure upon the auditory nerve during its course, or 
which may cause any change at its origin and in the fourth 
ventricle. It is well known to you, from cases in the 
medical wards, that the hearing is not unfrequently very 
much affected in apoplexy, cerebral tumors, inflammation 
of the brain and its membranes, and in hydro-cephalus 
internus, and that the symptom of deafness often aids us 
in diagnosis. 

I may only briefly allude to aneurism of the basilar 
artery as a not unfrequent cause of deafness, and of severe 
tinnitus aurium. The English authors, Gull and Ogle, and 
recently Griesenger, have particularly called our attention 
to the fact that an aneurism of this variety not unfre- 
quently impairs the function of hearing, by pressure on 
the auditory nerve. The latter named author mentions 
the following symptoms as characterizing the disease, that 
is, he states that they rarely occur in other forms of cere- 
bral disease; difficulty in swallowing, occasionally spas- 
modic deglutition, impairment of hearing, or complete 
deafness (often appearing at intervals, with great tinnitus), 
difficulty in respiration and articulation, interference with 
the excretion of urine; without any impairment of the 






DEAFNESS FROM CEREBRO-SPINAL MENINGITIS. 5II 

intellectual functions — and finally paraplegia or general 
weakness of all four extremities. 1 

A constant sensation of knocking in the back part of 
the head should not be lightly considered. 

Deafness from cerebro-spinal meningitis. — I must 
also allude to the relative frequency of aural affections 
in epidemic cerebro-spinal meningitis. One of the most 
common complaints of the patient in the beginning of 
this affection, is, of noise and singing in the ears. At 
the same time pain in the ear and aural hallucinations 
occur, and very often more or less impairment of hearing, 
which may become complete deafness. These symptoms 
do not so often appear in the latter course of the disease 
as in the beginning. The patient usually becomes deaf in 
both ears. The deafness frequently remains as an incura- 
ble residuum of the disease, and seldom disappears. 

Numerous pathological changes, according to the reports 
of post mortem examinations, which have, however, not 
been very numerous, seem to indicate that the disturb- 
ances of hearing occurring in cerebro-spinal meningitis, 
very often depend upon morbid processes in the fourth 
ventricle. 

We can hardly accept the view of Hirsch 7, and Ziemssen, 
that pressure of the product of inflammation upon the 
nerve after it has left the medulla oblongata, is more fre- 
quently the cause of the deafness, since on the one hand 
the acoustic nerve has not unfrequently been found buried 
in pus, without there being a trace of deafness during the 
course of the disease, and, on the other, paralysis of the 
facial nerve has been very rarely observed, as accompanying 
this form of deafness. 

Inflammation and collections of pus in the cavity of the 

1 Archiv fur Heilkunde, 1862, 6, s. 61. 

1 Vide Hirscb on "Meningitis cerebro-spinalis," Berlin, 1 8 66, which I have freely used. 



512 DEAFNESS FROM CEREBRO-SPINAL MENINGITIS. 

tympanum have been found in several cases. We may 
possibly imagine that this has resulted from the careless 
use of cold applications to the head. Is it not possible 
that the pus formed at the base of the brain, following 
the auditory nerve and its tuft-like expansion, may enter 
the labyrinth? 

A. Heller found the vestibule and cochlea in a state of 
purulent inflammation in two cases. The question occurs 
whether this internal suppurative otitis occurred inde- 
pendently and at the same time with the inflammation of 
the membranes of the brain and the spinal cord, or whether 
it is to be regarded as consecutive, as a continuation of the 
meningitis following the course of the neurilemma. Heller 
takes the latter view, judging from the appearance of the 
nerve, which he found in both cases saturated with pus. 
It is to be regretted that the labyrinth has, up to this time, 
been so rarely carefully examined in cases of cervical spasm. 

Treatment. — Inasmuch as marked improvement some- 
times occurs in this variety of deafness, we should never 
neglect in the beginning to exhibit the so-called resorb- 
ents (among which remedies good nourishment certainly 
ranks high). Injections of iodide of potassium through 
the catheter, may be of value in recent cases. In old 
cases, such as usually come to the aural surgeon, I have 
never seen any decided benefit, either from local or general 
treatment. Only once, have I seen any great benefit to the 
hearing from local treatment (the use of Politzer's method 
and the catheter). In this case, however, before my treat- 
ment was begun, some of the hearing power had returned 
after absolute deafness had existed for six months. 

After these observations on the different varieties of 
nervous deafness which we are as yet able to distinguish, 
the important question arises — what will justify us, in 



DIAGNOSIS OF LABYRINTH DISEASE. 513 

individual cases, in considering the impairment of hearing 
as dependent upon morbid changes in the parts of the ear 
beyond the cavity of the tympanum? It is only in rare 
cases that the history of the patient will aid us to form 
any definite conclusions. The objective appearances in a 
pure affection of the labyrinth or cerebrum, are negative, 
since the membrana tympani and Eustachian tube will be 
found in a normal condition. The appearances are also 
negative, however, in those cases of great impairment of 
hearing, which are chiefly or exclusively dependent upon 
morbid processes in the cavity of the tympanum, that 
have become localized on the two fenestras. 

In the case of diseases of the eye, we have visual tests 
that enable us to form definite conclusions as to whether 
there is any disease of the optic nerve and retina existing 
in conjunction with the turbidity of the dioptic media. 

The physiology of the sense of hearing has, unhappily, 
thus far, not taught us what degree of deafness may arise 
from simple peripheric causes, and from what point we 
must necessarily suppose that there is an affection of the 
nervous apparatus. Even if we can connect certain higher 
grades of deafness, on general hypothetical grounds, with 
a lack of perceptive organs, still every intimation of 
a settled boundary line is wanting, in front of which, peri- 
pherical interference with the conducting of sound alone 
is possible, and behind which, only dullness of the brain 
or the acoustic nerve and its expansion is imaginable. It 
is certain, and established experience proves, that primary 
morbid processes in the cavities of the tympanum produce 
a high degree of deafness, perhaps with an inclusion of 
the influence which they exercise through the fenestra in a 
mechanical way upon the contents of the inner part of the 
ear. Let us consider, by way of illustration, a case where 
the stapes is immovable, and surrounded by masses of 
bone ; consequently the fenestra ovalis is quite shut, and 

6S 



514 DIAGNOSIS OF LABYRINTH DISEASE. 

the membrana tympani secundaria is converted into a thick, 
inelastic or chalky plate, and the entire canal of the fenes- 
tra is filled with a compact plug of connective tissue; 
nevertheless, the labyrinth may still be normal, but the 
acoustic fibers can be reached only by those vibrations 
which are transmitted to them through the denser parts, 
namely, the skull bones. 1 

The diagnosis becomes very difficult if there are dis- 
tinct catarrhal conditions, either in the membrana tympani 
or Eustachian tube, and a question arises as to whether 
the impairment of hearing, etc., depend solely on the 
peripheral affection, or if there is still a deeper seated one 
which may be considered as a secondary process. 

We often find in persons whose hearing is impaired, and who have 
formerly suffered from constitutional syphilis, and especially in child- 
ren with syphilitic parents, that there is an impairment in hearing 
tones through the bones, which is not in perfect accord with the 
amount of trouble in hearing conversation. Perhaps there is here a 
specific affection of the labyrinth. 

This question as to whether the labyrinth has been 
affected, is, in certain cases, of great practical importance 
with relation to the prognosis. 

We have already seen how much testing the conduction 
of sound through the bone, especially by the tuning fork, 
may do to aid us in this respect. I need only to recall to 
your mind the fact that in cases of deafness on one side 
only, or where the degree of impairment of hearing was 
very different on the two sides, this method may furnish 
some very decided evidence as to the situation of the 
affection. 

In view of the great uncertainty in the diagnosis of 
nervous deafness, which in the most cases must be one of 
probability only, and in view also of the paucity of con- 

1 Vide Moos on same subject, Archiv fur Ohrenheilkunde, B. II, 3, s. 190. 



BLOOD SUPPLY OF LABYRINTH. 515 

elusions which the pathological anatomy of these parts has 
as yet furnished us, some general observations as to the 
relative frequency of peripheric and nervous affections of 
the ear may be allowable. In the eye, as is well known, 
diseases of the retina and optic nerve are much less fre- 
quent than affections of the tunics and dioptic media. 
Yet the conditions in the eye are more favorable for the 
development of disturbances of nutrition in the nervous 
apparatus than is the case in the ear. The retina and the 
entrance of the optic nerve are in an elastic sphere 
which is exposed to external influences and accidents, as 
well as to a change of pressure from within. The retina 
is also connected to the brain, as well as to the choroid 
and vitreous humor. The internal ear is independent, both 
as to its nutrition and osseous capsule, of the other parts 
of the ear. Its artery, the auditiva interna, does not come 
from without, like the vessels of the external and middle 
ear — from the carotid, but from the cerebrum, arising from 
the subclavian artery. It springs either immediately from 
the basilar, or from the inferior cerebellar artery. According 
to the examinations which have as yet been made, there does 
not always seem to be a constant connection between the 
vessels of the middle and external ear. Thus, secondary 
disturbances of nutrition of the labyrinth, proceeding 
from the vascular current, can only be produced by con- 
gestion and hyperemia within the skull, and not from the 
. same conditions in the peripheral divisions of the ear. 
The labyrinth is also formed much earlier than the petrous 
bone. Its ossification is entirely independent of that of 
the surroundings. 

Hyrtl 1 says that the isolated injection of single vessels 
is alone able to furnish conclusions as to certain condi- 
tions, and states that the question as to the complete inde- 
pendence of the vessels of the auditory labyrinth from all 

1 Handbuch der Zergliedeungs Kunst, s. 652. 






516 VOLTOLINI ON LABYRINTH DISEASE. 

its neighbors is only to be determined in this way. Henle 1 
also says: "All these vessels of the labyrinth form an 
independent vascular territory. When the art auditiva 
and meningea media are injected with different materials, the 
labyrinth alone is of the color of the auditiva; the re- 
mainder of the temporal bone is of the color of the me- 
ningea media. 

We are obliged, therefore, in view of what is as yet 
known, to believe that the seat of the affection of the ear 
is much less frequently found in the labyrinth than in the 
sound-conducting structures and spaces. Of course this 
view is only valuable in the want of a better — salva 
meliora y as the lawyers say — and until pathological anatomy 
shall show us a greater frequency of primary changes in 
the internal ear. 

Under the title of " acute inflammation of the membranous laby- 
rinth, generally considered to be meningitis," 2 Voltolini describes 
an acute disease having severe cerebral symptoms, fever, vomiting, 
etc., in which the patients who are chiefly children, become quickly 
deaf, and usually perfectly so, and after which a staggering gait 
remains for a long time. According to Voltolini, there is no doubt 
that the labyrinth is destroyed in this disease; "a diagnosis may be 
made from the symptoms merely." He even goes further and says : 
"I would almost deny the existence of cerebro spinal meningitis, and 
consider it as an acute inflammation of the labyrinth." Apart from this 
latter statement, which reminds us of Erhard, Voltolini's certainty 
in the diagnosis is unintelligible, since he himself confesses that he 
has not yet had an opportunity of proving the existence of this new 
form of disease on the cadaver. It is possible, that in the class 
of cases in question, which are unfortunately not rare, that we have 
an inflammation of the labyrinth. We may at least assume this as 
probable. Whoever does more is acting in an unproper and unscientific 
way. 

i Handbuch, B. IV, s. 123. 

2. Butler & Brinton's Half- Yearly Compendium, part I, p. 74. Monatsschrift fur Ohren- 
heilkunde, No. 1. 



DIAGNOSIS OF LABYRINTH DISEASE. 517 

Where a doubt exists whether we have to do with a 
catarrhal or nervous difficulty in hearing, whether with 
disease of the middle or the inner part of the ear, you 
will do well, in my opinion, in every relation, scientific 
as well as humane, to consider the first form as the more 
probable one; especially since in this event a proper treat- 
ment, in most instances, at least, is able to stop the pro- 
gress of the affection, while real changes in the inner 
part of the ear, if not dependent upon anomalies of 
blood and circulation, are, as a matter of course, almost 
entirely removed from our therapeutic interference. 

I have tried strychnine, through the catheter, endermatically, and in 
sub-cutaneous injections, as well as electricity, without, however, being 
able to see any especial results. 



LECTURE XXIX. 

noises in the ear, or tinnitus aurium. 
Otalgia. 

Gentlemen: We may to-day, devote ourselves to the 
study of those states of irritation of the auditory nerve 
which are known by various names, such as noises in the 
ear, buzzing in the ear, and which we in general terms 
may designate as subjective sounds — subjective aural sen- 
sations. The causes of these sensations in the ear, which 
do not depend upon an irritation of the organ from ex- 
ternal sounds, may lie in the various parts of the ear, and 
depend upon the most difficult affections, just as we have 
met with tinnitus aurium as one of the symptoms of most 
of the affections of the ear that we have as yet studied 
together. 

Each irritation of the acoustic nerve, from any direc- 
tion, will declare itself by sensations peculiar to this 
nerve. 

The subjective sounds in the ear must always be re- 
garded as an expression of an irritation of the auditory 
nerve, whether of its trunk or its terminal expansion in 
the labyrinth. In this view, however, we do not include 
those cases where real sounds exist in the interior of the 
ear, or in its immediate vicinity, the so-called internal 
sounds (Binnen gerausche). 

You see, that the subjective auditory sensations are 
closely connected to nervous deafness, since both depend 
upon a morbid condition of the nervous apparatus. They 



TINNITUS AURIUM. 519 

differ, however, from each other in the following respect: 
the former exhibits itself by an increased functional 
power, although a perverted one; the latter by a diminu- 
tion. Of course the two conditions may coexist, and this 
is very frequently the case. 

The descriptions of the various sounds which the 
patients hear in their ears, are exceedingly various. ' They 
are usually dependent, to some degree, upon the occu- 
pation, habits of thought, etc., since patients usually de- 
scribe them as like the sounds that they are in the habit 
of hearing in their daily life. 

Some of the comparisons made are very original. A young 
peasant thought the tinnitus in his ear, was like the sound of a mar- 
mot (German mole) whistling in his ear. Another patient described 
the noise as like "an abominable growling noise, as if a night-watch- 
man sat in his ear, and was grumbling through his hour." (This has 
reference to the practice which the watchmen have in some old 
German towns, of singing a song at the beginning of each hour of 
the night. St. J. R.) In the summer of 1866, during the war, 
patients in Wiirzburg, who suffered from tinnitus aurium, complained 
of the noise of drums, the rattling of ammunition wagons, etc. 
We thus had an opportunity of seeing the influence of imagination, 
and the effect of events, daily occurrences upon the subjective auditory 
sensations. 

I once saw a deaf composer who had in other respects a normal 
mental nature, who informed me that he continually heard a certain 
hymn in his ear the same one that had made his name famous. 

A shorter or longer after sound of certain monotonous vibratory 
impressions, to which a person has been exposed for some time, is 
very frequent, e. g., after a journey in the railway cars, or after 
remaining near a large waterfall, and so on. 

Continuous, and rhythmically interrupted sounds should 
be distinguished from each other. Some patients speak 
of several kinds of tinnitus as existing at one time, so 
that as they assert, one may be diminished under the 
treatment, while the other remains unchanged. Some- 



520 TINNITUS AURIUM. 

times the patients are not able to fix upon one ear as the 
situation of the affection, but are very undecided about 
the matter, or say that the noise is less in the ear than in 
the head, or in the back of the head. 

One patient only — she was from North Germany 
spoke of a pleasant sort of tinnitus. "The tones were s< 
remarkable — like the most charming notes of a bird 
that I often recall with regret this one pleasant feature oi 
my disease." 

(By a strange coincidence I have just seen and recorded 
the case of a lady suffering from disease of the ear, who 
described the tinnitus as an exceedingly pleasant sound. 
St. J. R.) 

Generally, however, the noise is very unpleasant, even 
painful. Many patients assert that their deafness is the 
lesser trouble, and entreat the surgeon to free them from 
this affection, at whatever cost, because it does not allow 
them a quiet moment, and prevents them from working, 
thinking, and even from sleeping. There are cases where 
such a tinnitus aurium has caused the subject to commit 
suicide. 

(I know of one such case, and I have been informed of 
another. St. J. R.) 

This condition of irritation of the auditory nerve may 
be caused by various morbid processes. We find subjec- 
tive sounds in all abnormally excited conditions of the 
brain, either proceeding from this organ itself, or reflected 
upon it. In this view we do not include actual cerebral 
disease. This is the case after any sort of poisoning or 
intoxication, especially after the use of quinine; in some 
anomalous conditions of the blood (anaemia and chlo- 
rosis) ; in temporary as well as permanent hindrances to 
the circulation; (in some cases of cardiac valvular insuf- 
ficiency, just as in fainting); and in connection with a 
class of indefinable morbid symptoms, to which the vague, 



TINNITUS AURIUM CAUSES. 521 

but as yet not to be banished names, relaxation of the 
nerves, over irritation of the nerves, nervousness, etc., 
have been given. 

Tinnitus aurium much more frequently depends upon 
abnormal conditions which may be found in the ear itself. 
We always find it in acute inflammation of the membrana 
tympani, and of the cavity of the tympanum, and in all 
the conditions that increase the pressure upon the fluid of 
the labyrinth, whether the membrana tympani be pressed 
inward by cerumen, or the tube be closed, and thus the 
drum, with the ossicula, lie farther inward. The stapes 
and its surrounding membrane, or the membrane of the 
fenestra ovalis, may be directly forced more towards the 
labyrinth by some cause. Every thickening or rigidity of 
the membranes of the fenestras, therefore, if connected 
with great tension, may of itself produce very disturbing 
tinnitus. Chronic catarrh is the most common cause of 
impairment of hearing, and tinnitus aurium seems to most 
frequently result from it in one way or another. 

A shortening of the tendon of the tensor tympani 
muscle, may be a very frequent cause of a tinnitus, that is 
only momentarily improved by the use of the air bath. 
Politzer first called attention to this, and we have already 
spoken of it. 

Every increase of the intra-auricular pressure, of course, 
causes an abnormal irritation of the nervous expansion of 
the acoustic nerve in the fluid of the labyrinth. It is pos- 
sible that it may also cause disturbances in the circulation 

i and nutrition, such as occur in the globe of the eye when 
its walls and its contents have been for a long time sub- 

I ject to abnormal conditions of pressure. 1 

Very severe tubal catarrh often occurs, however, with 

I distinct pressing inward of the membrana tympani, with- 

1 out tinnitus aurium. Cases have also been examined post 

i Wiener me<Jiz Wochenschrift, 1865, Nos. 67-72. 

66 



522 TINNITUS AURIUM CAUSES. 

mortem where, according to the appearances of the stapes, 
there must necessarily have been considerable pressure 
upon the contents of the labyrinth, and yet the patient 
has never suffered from tinnitus, except at the inflamma- 
tory beginning of the disease. We may accept the view 
of Schwartze, that the contents of the labyrinth may be 
gradually accustomed to a certain increase in pressure 
without the occurrence of these subjective auditory sensa- 
tions. 1 Besides, we may remember that any interference 
with the base of the stapes will differently affect the ear, 
according as the membrane of the fenestra rotunda is 
normally elastic or thickened. This may explain the fact 
that tinnitus aurium usually increases with the age of the 
patient. I have also observed severe tinnitus in very 
young children, but this symptom is comparatively less 
frequent and troublesome than in adults. 

Chronic hyperemia of the ear will also produce this 
troublesome symptom. We not unfrequently, however, 
meet with very great vascular development on the mem- 
brana tympani, when the patient does not complain in the 
slightest of tinnitus. 

Aural catarrh without perforation of the membrana 
tympani, is much more frequently connected with tinnitus 
than the same disease where an opening exists. This is 
explained by the fact that the discharge of the secretion as 
well as the equalization of the outer and inner pressure of 
air, are rendered easier by the opening. 

Although affections of the peripheral parts of the ear, 
because of themselves occurring more frequently, most 
frequently produce conditions of irritation in the laby- 
rinth, the fact should not be overlooked that these latter 
may be caused by diseases within the labyrinth itself. 
The disease of the semi-circular canals described by Me- 

i Archiv fur Ohrenheilkunde, I, s. zi%. 












TINNITUS AURIUM. 523 

niere> of which we have already spoken, is always accom- 
panied by severe tinnitus aurium. 

Politzer found on the cadaver of two patients who had 
died of typhus, small ecchymoses in the vestibule, with 
catarrhal changes in the middle ear. Schwartze found 
great hyperemia of the cochlea in one case of typhus. It 
is conceivable that subjective sounds, such as occur in 
typhus, may depend on such morbid processes in the 
labyrinth. 

We have already observed that deafness and tinnitus 
occur from great concussions. Cases also occur, however, 
where after severe sounds the acuteness of hearing is not 
at all affected, but where there is the so-called false hearing 
in connection with ringing or singing in the ear In such 
cases we may believe that the terminal expansion of the 
auditory nerve, in consequence of the great concussion, is 
brought out of its position of equilibrium, and is thus 
placed in a temporary or permanent condition of irrita- 
tion. {Politzer.) Thus, I saw a young man, a short time 
ago, who, on the day before, had suffered from the explo- 
sion of a small toy pistol close to his left ear. Since then 
he had heard everything, even his own voice, in a less dis- 
tinct tone than normal, and he had a continuous ringing 
in his ear. He could hear a watch from six to seven feet 
on that side, while he heard on the other ten feet. The 
tuning fork was heard more plainly towards the right when 
placed on the center of the teeth. The tone of the watch 
was not as clear as normal from the left temple, while that 
of the tuning fork was not so distinct when from the left 
ear. The objective appearances were negative, apart from 
naso-pharyngeal catarrh. Air passes readily in through 
the catheter. Sounds are somewhat clearer in the left ear. 
Hourteloup' s artificial leech was applied to the left mastoid 
process. The day after his condition was the same. In a 
few days, under a purely expectant treatment, the ringing 



524 TINNITUS AURIUM CAUSES. 

in the ear and dullness of hearing was gone; last of all he 
got rid of the want of clearness in the sound of his own 
whistling. He finally heard the tuning fork with equal 
distinctness in both ears. It is more frequently the case, 
however, that the acuteness of hearing is considerably 
altered after such sonorous impressions. 

Cases also occur of severe tinnitus aurium, in which the 
hearing is normal or ample, that is, very little lessened. 
Hyperasmic processes in the naso-pharyngeal space have a 
great deal to do in causing such affections, extending, as 
they may, for some distance into the tube. 

Fleischmann relates an interesting case of tinnitus aurium^ arising 
from a foreign body in the Eustachian tube. A man complained for 
years of a continuous sound in the ear, and of a very peculiar sensa- 
tion in the pharynx, as if a hair had got into his mouth. On the 
post mortem section, a grain of barley was found projecting from the 
pharyngeal orifice of the tube, and reaching from there into the 
osseous tube. Such a case could now be diagnosticated by means of 
the rhinoscope, and possibly relieved. 

Every severe cold in the head is usually accompanied 
by a temporary tinnitus aurium. Quite often every other 
symptom disappears except the tinnitus. Gradually dimi- 
nution of the acuteness of hearing also occurs. To the 
hyperemia are then added the actual pathological changes. 
It is more rare, after an acute inflammation of the ear, that 
the hearing again becomes normal, while continuous tin- 
nitus remains. Such conditions, which may perhaps be 
referred to limited vascular anomalies, small aneurisms or 
varicose formations in the cavity of the tympanum, or in 
the labyrinth, are often very obstinate to local treatment, 
even though it be continued for years. 

Tinnitus aurium is an evidence of an irritated condi- 
tion of the auditory nerve. In consonance with this the 

1 Linke's Sammlung, II, s. 183. 



TINNITUS AURIUM CAUSES. 525 

condition of the whole nervous system, the general con- 
dition, and especially the social and psychological condition 
of the patient will always have an influence upon it. 

Heurnius 1 says: " Tinnitus aurium plerumque a flatibus originem 
habet" and now a days, our Franconian peasantry have an idea that 
wind from the stomach which has got into the ear, is the cause of the 
tinnitus. 

Even a very slight tinnitus becomes very troublesome 
when a patient is very much depressed, tired, or suffering 
from any bodily ailment. On the other hand, a regular 
life, good society and pleasant feelings have the contrary 
effect. The external influences that increase the tinnitus — 
sudden change of weather, very damp, or very dry and 
hot weather, and a very warm room — in chronic catarrh of 
the middle ear, are especially to be mentioned. Full 
meals, and especially the use of alcoholic stimulants, with 
very long continued bodily exercise, usually increase the 
tinnitus. On the whole the patients feel better in the 
open air than in a close room. 

Turck, of Vienna, first drew attention to the fact that a 
temporary effect could be produced upon tinnitus aurium 
by pressure of the finger upon the mastoid process. It is 
usually lessened by this pressure. Politzer confirms this 
view after numerous experiments. 

Benedict, has recently ascribed an extended importance to 
the reflex irritation of the auditory nerve, from the track 
of the tri-facial, based upon electric examinations. I have 
long observed the striking fact that some patients complain 
of an increase in the tinnitus, whenever they place the 
finger on certain parts of their face, the eyelids, temples 
or cheeks, or when they shave. 

I have already said, in speaking of chronic catarrh, that 
the existence of a continuous noise in the ear is an un- 

1 De morbus oculorum, aurium, etc., 1602. 



526 ENTOTIC SOUNDS. 

favorable prognostic sign. Other things being equal, in 
all affections of the ear, the prognosis is always more 
favorable when there is either no tinnitus or subjective 
sounds in the ear, or when they only occur at intervals. 
It is an extremely interesting fact, on the other hand, that 
sometimes tinnitus aurium occurs, or that which already 
exists during the treatment of chronic catarrh, is increased 
at the same time that the hearing is markedly improved, 
and the formerly deficient perception of tones from the 
bones is gradually increased. This state of things is not 
very frequent, however, and may only be explained by 
supposing that the sensitiveness of the acoustic expansion, 
which was previously diminished for all kinds of air im- 
pressions, is now increased, both for normal and morbid 
irritations. It much more frequently occurs, however, that 
the tinnitus and impairment of hearing increase and de- 
crease pari passu, in equal proportion. 

Apart from these purely subjective sounds, which are to 
be considered as symptoms of an abnormal irritation 
exerted upon the auditory nerve and its expansion, cer- 
tain acoustic sensations, which are caused by actual tone- 
exciting vibrations, are comprehended under the name of 
tinnitus aurium. These vibrations are not caused with- 
out the body, but are actually produced within it, and are 
called entotic sounds. 

Thus the internal sounds described by the patients as 
"striking," or "pulsating," are for the most part nothing 
more than vascular sounds having an arterial origin, 
whether arising from the internal carotid itself, which 
passes through the temporal bone in a sinuous course, 
or in the small arteries in and around the temporal bone. 
We may voluntarily produce temporary but very decided 
arterial sounds in the ear, by certain sudden rotary move- 
ments of the head, especially when lying in bed. 



VASCULAR SOUNDS. 527 

In cases where the contents of the venous sinus, which surrounds 
the carotid artery during its course through the bone, is changed into 
a coagulated rigid mass, every hindrance to the conduction of the 
pulsation of the artery is removed, and this is probably perceived by 
a pulsating sound in the ear. The same thing occurs when there is 
an aneurism of the artery, or when the osseous canal is narrowed at a 
certain point, so that a portion of the carotid comes in direct contact 
with the bone. 

Certain blowing and hissing sounds heard by chlorotic 
and anaemic patients, may also be referred to vascular 
sounds transferred to the petrous bone. I may recall to 
your attention the fact, that the internal jugular vein, that 
is, its bulb, quite often lies close under the floor of the 
cavity of the tympanum. Besides, as you all know, 
a portion of the wall of the transverse sinus is formed by 
the posterior portion of the temporal bone. All such 
sounds, occurring either in or on the ear, must act all the 
more powerfully on the auditory nerve, when the natural 
exit of sounds from the ear is hindered in any way, e. g., 
by thickening or abnormal tension of the membrana tym- 
pani. 

We may, therefore, believe that tinnitus aurium, much 
oftener than we have thought, has no connection with 
morbid irritation of the auditory nerve, but depends upon 
simple entotic sounds, which, although existing for a long 
time, have been first brought to perception by pathological 
changes in the sound-conducting apparatus. When so 
many patients speak of very different sorts of sounds, 
which increase or decrease under various influences, it may 
be that the two forms (perhaps we may designate the one 
variety as nervous tinnitus aurium, the other as material 
or acoustic) exist at the same time. 

It has already been mentioned that a knocking sound is 
often heard in the back part of the head, when an aneu- 



528 ANEURISM OF BASILAR ARTERY. 

rism of the basilar artery exists. Rayer 1 reports a case of 
pulsating tinnitus, isochronous with the beat of the 
heart, which was perceived by others than the patient, on 
auscultation, and which was momentarily checked by com- 
pression of the mastoid branch of the posterior auricular 
artery. There was no real aneurismal enlargement of the 
vessels, nor valvular insufficiency of the heart, or morbid 
tone in the aorta or carotid, so that the sounds seemed to 
originate in some peculiarity of the branches of the pos- 
terior auricular artery, or in some change of the parts. 
Rayer takes the opportunity to recommend the practice of 
auscultation in cases of tinnitus aurium, in order to dis- 
tinguish if the morbid sounds are perceived by the patient 
only, or if they may also be detected by the physician. 
Politzer also saw an old man who complained of continu- 
ous rough blowing sound in the ears, which was iso- 
chronous with the pulse, in whom a strong systolic mur- 
mur was perceived on auscultation, not only over the 
heart, but also on the ear and head. 

Just as in many rodentia and gnawing animals, insects 
and bats, the internal carotid passes through the side of 
the stapes, so in man, according to Hyrtl, z there is always 
a capillary arterial branch between the sides of the stapes, 
through to the promontory, and, exceptionally, there is a 
larger artery running through the stapes. When the last- 
named state ©f things exists, it seems to me scarcely 
questionable that pulsating internal noises in the ear de- 
pend on this communicated motion of the stapes, to which 
the patient may accustom himself, so as not to observe them, 
just as the miller does not observe the noise of his mill. 

The well known crackling sound, belongs among the 
internal sounds of the ear that may be objectively recog- 

1 Comptes rendres des Seances et Memoires de la Societe de Biologic Annee, 1854, p. 169. 

2. Vergleichend-anatom. Untersuchungen iiber das innere Gehororgan des Menschen und 
der Saiigethiere. Prag : 1854. S. 40. 






TINNITUS AURIUM. 529 

nized, that is, may be perceived by others. Many persons 
are able to produce this sound voluntarily. * It was 
formerly considered as depending upon voluntary contrac- 
tion of the tensor tympani, but according to Politzer 1 it 
results from the sudden drawing away of the membranous 
portion of the Eustachian tube, which occurs during con- 
traction of the tensor palati. Luschka expressed the same 
opinion at the same time. Lowenberg* also furnished 
further proofs that the tube opened when this crackling 
sound was made. 

Very many persons hear such a delicate crackling sound 
at every act of swallowing — especially when the mucous 
membrane is somewhat affected by catarrh — which may 
easily be mistaken for a sound in the ear. 

Boeck 1 has recently demonstrated, by a rhinoscopic exa- 
mination, that the tube opened in such a case. In a case 
which Schwartze* described as chronic spasm of the tensor 
tympani muscle, a visible contraction of the membrana 
tympani was seen at every crackle, together with elevation 
of the uvula. Certain temporary sounds that occur in 
the ear when catarrh exists, and which probably depend upon 
the bursting of a mucous bubble, or the like, should also be 
mentioned, as well as a peculiar rattling or flapping sound 
that some patients with impaired hearing complain of, as 
occurring in one or both ears when the head is shaken. 

Treatment. — I do not know any special treatment for 
tinnitus aurium. We must treat the disease which causes 
it. The subjective sensations in the ear comprehended 
under the term tinnitus aurium, most frequently depend 
upon the abnormal pressure which pathological changes on 

1 Wiener Medicinal Halle, 1862, No. 18. 
aMediz Central Blatt, 1865, No. 32. 

3 Archiv fur Ohrenheilkunde, II, s. 203. , 

4 L. C, II, s. 4. 

67 



53O TINNITUS AURIUM TREATMENT. 

the fenestrae of the labyrinth, and an increased projection 
inward of the stapes, cause to be exerted upon the fluid 
of the labyrinth. These changes on the fenestrae, and the 
altered position of the stapes, may depend upon disease 
situated either in front of, or behind the membrana tym- 
pani. This explains the fact that frequent air baths, the 
introduction of warm vapors, or medicated fluids injected 
through the catheter, often diminish the tinnitus, and the 
sense of pressure in the head that usually accompanies it, 
even in cases where scarcely any improvement to the hear- 
ing results from the treatment. 

(My experience shows, that I have oftener succeeded in 
improving the hearing than in lessening the tinnitus de- 
pendent upon chronic aural catarrh, although the sensa- 
tions of fullness in the head, and vertigo, are usually 
relieved. St. J. R.) 

The treatment of chronic catarrh and of tinnitus auri- 
um are usually one and the same. Diluted glycerine has 
very often done good service, either injected through the 
catheter, or dropped into the external auditory canal. 
Some persons immediately perceive a diminution of the 
tinnitus on pouring warm water into the ear. It is often 
necessary to tell the patient not to press a wad of cotton 
into the meatus. This is a very common kind of malprac- 
tice in Germany, which of itself alone may cause tinnitus. 

I have used all sorts of narcotics as additions to vapors 
and injections through the tubes, as instillations into the 
auditory canal, and rubbed behind the ear, and generally 
with not even a temporary benefit. I would most advise 
you to try an injection of cloroform mixed with olive oil 
or glycerine. Sometimes subcutaneous injections of mor- 
phine diminish severe tinnitus for a time. A vesicant 
also, sometimes, is of avail when a constant tinnitus is 
temporarily increased in severity. Rarefaction of the air 
in the auditory canal by means of an india-rubber tube, 



TINNITUS AURIUM IN THE INSANE. 53 I 

hermetically inserted into the meatus, generally lessens the 
subjective sounds, although usually for a short time only. 
In very desperate cases we may perforate the membrana 
tympani. Unfortunately the opening soon closes up. 

Tinnitus aurium in the insane. — It is a very important 

question, whether the aural hallucinations occurring in insane pa- 
tients, do not frequently depend on peripheric tinnitus, which is 
exaggerated by the patients. It would be well worth the trouble, if 
physicians for the insane would examine the ears of such patients. I 
am indebted to my esteemed friend Prof. Ludew Mayer, formerly 
director of the Insane Asylum, in Hamburg, for the history of a 
melancholic patient, who was relieved of a sound in the ear, seeming 
to the patient to be the cry of a child, by the removal of a plug of 
inspissated cerumen, which caused deafness of one side. The patient 
from that time on made a rapid and complete recovery. 

Very recently, Schwartze, an aural surgeon, and Koppe, a physician 
for the insane, have made this question a subject of investigation. 
They have reached some remarkable results as to the dependence of 
certain psychological symptoms upon peripheric aural affections. 
Schwartze says : " Subjective aural sensations, which are caused by 
demonstrable affections of the ear, may, in predisposed persons, espe- 
cially when there is any hereditary tendency to mental disease, 
become the direct cause of aural hallucinations, that may accelerate 
the outbreak of mental disease. I have treated such a patient for a 
long time, and she has been protected from a threatened attack by 
local treatment of the aural disease. Dr. Koppe, assistant physician 
to the Provincial Insane Asylum at Halle, examined this patient with 
me, and is convinced that the treatment caused the above-mentioned 
result. In other cases, insane persons, who suffer from aural disease, 
distinguish its tinnitus from their illusions or hallucinations. They 
hear their "sounds" simultaneously, but independently of the tinnitus 
aurium. 

Kbppe speaks in the same way, more in detail. He examined 
thirty-one insane persons in the above-named institution, in whom 
considerable disease of the auditory apparatus could be detected. In 
none of them, was there tinnitus, without, at the same time, the 
existence of aural illusions and hallucinations. Seven insane persons 
also had a chronic hyperemia of the vessels of the handle of the 



532 OTALGIA. 

malleus, and besides the subjective aural sensations, aural illusions 
and hallucinations. 

In two cases of inspissated cerumen, the tinnitus disappeared 
after the removal of the plugs of wax, but the hallucinations remained. 
In several cases, which are fully detailed, both the tinnitus and the 
hallucinations disappeared after local treatment of the ear. Two 
cases were particularly interesting, where only one ear was affected, 
and where the sounds were only heard on that side. 1 

Otalgia. — To these anomalies of the sensation in the 
ear we may add hyperasthesia of the sensory nerves of 
the ear. We usually call this nervous pain in the ear 
otalgia nervosa. Pain not depending on inflammation, 
called neuralgia of the tympanic plexus by Schwartze, 
occurs much more rarely than is usually believed. The 
error in diagnosis arises from an insufficient examination 
of the ear. 

There is, however, a pure neuralgic pain in the ear, hav- 
ing a typical course, which is an extremely troublesome 
affection. It most frequently results from caries of the 
molar teeth. In several such cases that I have observed, the 
pain disappeared when the carious tooth was removed, and 
in another it was removed by filling the cavity. In some 
cases I have used subcutaneous injection of morphine be- 
hind the ear. 

(Dr. Weir has kindly furnished me with the notes of a 
case where the removal of a carious tooth immediately 
relieved pain in the ear. St. J. R.) 

Pain in the ear seems also to occur as a reflex sensation 
from the pneumo-gastric. Gerhardt 1 has observed severe 
pain in the ear in ulcerative destruction of the epiglottis, 
"almost, constantly." It may either exist permanently, 
or only during the act of swallowing. 

i Berliner Klinische Wochenschrift, 1866, Nos. 12, 13, allegem Zeitschr fur Pyschiatrie, 
1867. Bd. XXIV. 

a Virchow's Archiv, B. XX VII, s. 5. 



LECTURE XXX. 

DEAF-MUTEISM. 

Its nature \ and the causes of its origin; medical and educa- 
tional treatment. 

THE APPLICATION OF ELECTRICITY IN DISEASES OF THE EAR. 

Faradization of the ear; the constant current. 

Ear-Trumpets. ^ 

Gentlemen: The subject of deaf-muteism naturally 
follows the discussion of nervous diseases of the organs 
of hearing. A child that is born deaf, or that has become 
so in the earliest years of its life, never learns to speak. 
Even children who have learned to talk, again lose this 
power if they have become deaf at an earlier age, say about 
the seventh year. Even from the years of eight to nine, 
conversation may be very indistinct from loss of hearing. 
Although we usually speak only of a congenital and an 
acquired form of deaf-muteism, it seems to me practically 
necessary, and of vital importance, to distinguish three 
original varieties. 

I. Congenital deaf-muteism, comprising cases where the 
child has never heard 3 and has never spoken. 

II. Early acquired deaf-muteism, where a child actually 
hears a little, but not well enough to speak as one of his 
age should. 



534 DEAF-MUTEISM. 

III. Late acquired deaf-muteism, a variety comprising 
those cases where the child spoke for a longer or shorter 
time, but lost the power of speech with the hearing. 

It is often difficult in individual cases to decide whether 
we are dealing with the first or the second form, since the 
statements of the relatives, that the child for a time did 
hear, frequently depend upon very slight observations. 
Many parents will not willingly believe that a child of 
theirs should be deaf and dumb from birth. 

The pathological conditions in both the congenital and 
acquired form of deaf-muteism scarcely differ from those 
that are found in persons who have lost their hearing later 
in life, but who have not become dumb. We find exten- 
sive diseases of the cavity of the tympanum, or a defec- 
tive development of the sound-conducting apparatus, just 
as often as abnormities in the deeper parts, the labyrinth, 
nerve, or in the brain, at the origin of the auditory nerve 
from the fourth ventricle. Among the appearances in the 
labyrinth, partial and complete absence of the semi-circular 
canals are very frequently mentioned. Not unfrequently the 
examination of the internal ear furnishes a purely negative 
result, so that the distinct traces of catarrhal inflammation 
in the cavity of the tympanum must be considered as the 
essential cause. It seems to me very probable that peri- 
pheral changes in the organ of hearing may alone produce 
deaf-muteism. We must be especially guarded against 
considering deaf-muteism as an entirely isolated and dis- 
connected, specific morbid condition, as it not unfrequently 
seems to be considered by physicians, as well as by teach- 
ers of the deaf and dumb. 

Let us take a case that we know may occur. In the event 
of an acute or chronic catarrh of the ear in the first or second 
years of life, thickening of the fenestra rotunda, in connec- 
tion with the anchylosis of the stapes, is seen. These struc- 
tural changes will in any case cause a very great impairment 



DEAF-MUTEISM CAUSES. 535 

of hearing, perhaps about that which in an adult would ena- 
ble him to understand only when the words are pronounced 
slowly and loudly close to his ear. Such will be the case 
with adults who formerly heard, and who have been always 
accustomed to speech, and who are still able to indicate 
the fact that the words do not sound distinctly to them. 
In the case of the adult, reading from the mouth of the 
speaker, and putting together the half heard and broken 
sentences, will very greatly assist the listener. But how 
will the same amount of impaired hearing affect a little 
child? It has not as yet learned to hear, so to speak, or 
to fix its attention upon speech. The words of the mother 
are to the infant, the same as those of an unknown tongue 
to us, when we do not know what the words reaching our 
outer ear indicate or express. 

Such a child, who only distinctly perceives what those 
around him say, under peculiarly favorable circumstances, 
that is, only exceptionally, and who, as a consequence, 
must learn the sense and meaning of words very gradually 
and slowly, or perhaps not at all, such a child, I say, will 
soon cease to interest himself in what is said, and will 
chiefly confine himself to the interpretation of signs and 
gestures, and will still less endeavor to reproduce words, 
because that which alone excites the disposition to speak 
I ourselves — the speech of others — does not exist for him. 
For the above-named reasons the habit of hearing will 
be less and less practiced, the child impresses us as being 
a completely deaf creature, to whom it would be folly to 
speak. The inducement is wanting, and thus the child 
will become more and more deaf and dumb, who at first 
was really only hard of hearing. The same child, however, 
if we speak to him slowly and distinctly in the ear, just as 
we do to the adult who is deaf, and if the objects are be- 
fore his eye which we are talking about, will at all events 
learn to hear, and even to understand what the words 



536 DEAF-MUTEISM TREATMENT. 

express. He will take an interest in conversation, and try- 
to imitate what he has heard, and even endeavor to speak 
himself. He will simply remain hard of hearing, and be 
able to express himself tolerably well. 

We should not leave out of consideration the material 
changes which appear under the form of regressive meta- 
morphosis, in consequence of the want of a specific irri- 
tation in the auditory, nerve, and perhaps, in the brain. 
These, in the very nature of things, must be much more 
quickly developed in the infantile organism than in a fully 
grown person. 

The condition of things is similar when a child that 
already speaks becomes very hard of hearing in early life. 
Even in an adult an imperfect hearing of ones own voice 
has an unpleasant influence upon the modulation and con- 
trol of the voice. A child, on the other hand, who does 
not hear those around him well, nor his own voice, soon 
loses the power of speaking distinctly, and of speaking at 
all, unless great strictness is observed in teaching him to 
speak distinctly, by constantly using — if necessary, by 
means of a hearing tube or trumpet — the little hearing 
power that he has. It is also necessary to accustom the 
child to watch the mouth of the person. 

You will now understand how we are able, by means of 
great personal attention and methodical instruction in 
speaking and vocalizing, to cure certain forms of deaf- 
muteism, or, more correctly speaking, to prevent high 
degrees of impairment of hearing, from developing into 
deaf-muteism. The treatment is very similar to those 
methods of education which are now carried on in the most 
approved institutions for deaf-mutes, only that at a later 
period the vocal organs have lost, to a great extent, their 
capacity for modulation, and a characteristic, animal-like, 
howling appears, unless very great care be taken by the 
teacher, in the vocal education. 



. 



INSTRUCTION OF DEAF-MUTES. 537 

B. Meckel^ a very capable instructor of the Deaf and Dumb in 
Camberg (in the former Duchy of Nassau), has done me the favor, 
at my request, to write me a letter containing some criticisms on the 
lecture on deaf-muteism, as it appeared in the former editions of this 
work. He writes, among other things : " It is of course true that 
deaf-mutes who are brought into an institution for the education of 
deaf-mutes in their eighth year, or later, are frequently awkward in 
the use of the organs of speech, especially in that of the tongue. 
According to my experience, however, I cannot admit that the power 

I of modulation is to any great extent destroyed by the non-use of the , 
organs of speech. Much here certainly depends on the manner in 

I which the instructor seeks to develop sounds from the scholar, and 
the way in which he causes him to use them. In this institution we 

I practice those just received, for some months in a very exact and 
correct production of the consonants and their different combina- 
tions, long and short, just as they occur in conversation, without 
adding the vowels. In this manner speech becomes very flexible, 
and when the vowels are employed, in speaking words, a normal tone 

! of voice is secured by most deaf-mutes. You will only find the 

j animal-like, howling voice, in our institution, in those deaf-mutes 
incapable of cultivation. In producing a good tone in the speech, 
the remnant of hearing power which the deaf-mute may have, as well 
as the intonation of the voice, the length and shortness of the sylla- 
bles on the part of the teacher, come into consideration." 

As a matter of course, medical treatment must be intro- 
duced as soon as possible, with the systematic instruction. 
I could relate to you, from my practice, several cases in 
which deaf-muteism was obviously prevented, or was 
checked, or caused to retrograde, when in a condition of 
development. For instance, there is under my treatment at 
present, a child four and a half years old, who, from the 
first months of his existence, has suffered from a profuse 
discharge from both ears, and is conscious only of loud 
sounds. Until within a few months, when I saw him for 
the first time, he was able to produce only an inarticu- 
late barking, and other sounds which were unintelligible 
j even to the mother, so that he was already properly con- 
68 



53$ TREATMENT OF DEAF-MUTES. 

sidered a deaf-mute child. Under a local treatment of 
the profuse discharge from the ear, this deaf-muteism soon 
decreased, and with the decrease of the discharge the child 
manifestly commenced to notice noises which were made 
around him, and especially the words of bystanders; and 
also made attempts to imitate what was said. These 
attempts were encouraged as far as possible, and the child 
was employed as much as possible in speaking words and 
sentences. In this manner I succeeded not only in de- 
creasing the degree of impairment of hearing, but after a 
few months the child possessed a tolerably distinct, and at 
any rate quite intelligible language. With it, at the same 
time, the whole bearing of the child, who had been obsti- 
nate and unmanageable before, was changed; he became 
more docile, and lost something of his truly animal liveli- 
ness, which manifested itself in the expression of the face, 
and in the continuous, squirrel-like mobility of his whole 
body. (This excessive physical activity seems to be a 
characteristic of nearly all of our uneducated deaf-mutes. 
St. J. R.) Without these local applications and the correct 
guiding care of those about him, the child would certainly 
soon have been counted among the deaf and dumb. 

You are now able to see why such great importance 
is to be attached to diseases of the ear in the first pe- 
riods of human existence, and why, in the former lec- 
tures, I so earnestly urged on your consideration a care- 
ful investigation and observation of them in the case of 
little children; and why, in consideration of their possibly 
great importance, I brought to your cognizance facts and 
minute details which have heretofore existed only anatomi- 
cally, and for which the practical or clinical estimate and 
decision are, to a great extent, yet to come. 

The same affection of the ear which only makes an 
adult hard of hearing, may deprive the child at the same 
time of language, and cause him to remain, during his 



TREATMENT OF DEAF-MUTES. 539 

whole future life, in a lower state of social and mental de- 
velopment. We must not, therefore, omit, or consider 
trifling, anything that can in the least degree give an ex- 
planation of the appearance and origin of diseases of the 
ear in children. 

Fully developed deaf-muteism, which has existed for a 
long time, is considered incurable by all persons capable 
of judging. The much vaunted cases of cures of old' 
deaf-mutes seem to be founded in delusion, or in igno- 
rance of the fact that from the beginning a large propor- 
tion of deaf-mutes are not absolutely deaf, but are still in 
possession of a certain remnant of the faculty of hearing, 
on the amount of which the capability of further develop- 
ment depends. 

I do not wish to say, of course, by the foregoing, that 
acquired deaf-muteism is always to be referred to the con- 
sequences of a high degree of impaired hearing, and that 
the latter can always be checked or prevented by an early 
local and linguistic treatment. This may not infrequently 
be the case, but we must not forget that in the period of 
infancy, as well as in old age, there is a great tendency to 
affections of the brain, and especially to diseases of the 
cavities of the cerebrum and its integuments. It might 
be possible, also, that as Voltolini supposes, there is a cer- 
tain disposition, in the case of children, to frequent and 
severe diseases of the labyrinth, and that therefore, in 
childhood, a complete deafness develops itself proportion- 
ably more frequently than is the case in adults. 

I should also mention that an hereditary or family dis- 
position to deaf-muteism can not be denied. Although 
the affection is comparatively rarely continued to the child- 
ren, yet quite often a number of deaf-mutes occur in one 
family. Extensive statistical tables also show that rela- 
tively more deaf-mutes result from the marriage of near 
relatives, than where the offspring are the result of other 



54° EXAMINATIONS OF DEAF-MUTES. 

connections. Liebreich mentions intermarriage as a cause 
of retinitis pigmentosa, with which deaf-muteism is often 
associated. Scarlet fever should be prominently mentioned 
as a cause of acquired deaf-muteism, as well as the different 
forms of meningitis and continued fever. 

(An examination of 296 different cases of deaf-mutes in the excel- 
lent institutions for the education of this unfortunate class in this city, 
and in Hartford, Connecticut, made by my friend, Dr. G. M. Beard, 
and myself, seem to confirm the views of the author, that the usual 
causes of the deafness causing muteism in children, are about the 
same as those which obtain in cases of deafness occurring in adults. 
I am inclined to believe that the remote causes which are, moreover, 
often assumed rather than accurately known, such as " fright of the 
mother during gestation, intermarriage, etc.," have been studied 
somewhat too much, to the exclusion of the proximate causes which 
may be usually ascertained by the ordinary objective examination of 
the ear by means of the otoscope or ear mirror, and speculum. 

The elaborate statistical tables of the causes of deaf-muteism have 
been usually made up by laymen, who do not realize the fact that 
remote causes, of themselves, are of very little value, since they 
lead to no definite ideas as to what pathological changes form the 
proximate causes. These tables are also made up, to a large extent, 
of the statements of parents and friends, and thus are very often a mere 
matter of guess work. The only manner of obtaining a knowledge 
of the etiology of deaf-muteism is, to first secure a thorough objec- 
tive examination, and then to add to this the history of the patient, 
noting the amount of reliance to be placed upon it. Post mortem 
examinations should of course be obtained, with which to verify the 
diagnosis. 

Of the cases examined by Dr. Beard and myself (296 in all) 182, 
or 61 per cent., were probably congenital; 114, or 39 per cent., 
were probably acquired. 

In the so-called congenital cases, all but thirty were found to ex- 
hibit changes on the membrana tympani, which indicated local 
inflammation as the proximate cause of the deafness. It is also 
interesting to note that very many of the deaf-mutes are much 
annoyed by tinnitus aurium. This fact also indicates the inflamma- 



ELECTRICITY IN AURAL DISEASE. 54 1 

tory nature of the affection which destroyed the integrity of the 
organ of hearing. 1 St. J. R.) 

The use of Electricity in Aural Disease. 

Electricity has been warmly recommended from the 
time of the last century up to the most recent period, for 
nervous, and in fact for all varieties of deafness, in the 
most different methods of application. We should be a 
little distrustful of any means of treatment that is con- 
sidered valuable in such a great variety of cases. We 
should carefully examine into the favorable results which 
have been reported, to see if an exact diagnosis, or at least 
a thorough examination of the affected parts has preceded 
the treatment. We must be doubly careful here, since 
some other application is generally connected with that of 
electricity, which of itself might relieve some forms of 
deafness. I mean by this the frequent filling of the audi- 
tory canal with lukewarm water. We know that accumu- 
lations of cerumen, dried epidermis, etc., are not unfre- 
quently the cause of impairment of hearing. Such cases 
are not unfrequently found among those who have been 
treated by electricity, without any previous examination of 
the ears. 

A person who had been cured of deafness by electricity 
once, quite honestly, told me that he has been surprised at 
the amount of fluid ear-wax which was secreted after each 
application of the agent, so that his handkerchief with 
which he cleaned the ear was covered by great brown spots. 

But apart from such cases, and aside from recent cases 
of tubal catarrh, or of catarrh of the cavity of the tym- 
panum, where the hearing often varies very much without 
any treatment, there are related, by creditable authority, 
many cases where impaired hearing has been improved by 

1 The appearance of the Membrana tympani and Fauces in 296 cases of acquired and con- 
genital Deaf-muteism. American Journal of the Medical Sciences, Vol. LIU, p. 399. 



542 ELECTRICITY IN AURAL DISEASE. 

the use of electricity, cases that were of long standing, and 
which had been examined and treated by various competent 
aural surgeons. 

The use of electricity in diseases of the ear should 
therefore not be dismissed so contemptuously as it is by 
some aurists, but we should endeavor, by experiments 
with the agent, to get an exact knowledge of the proper 
method of application, and of its effects. There is much 
to be desired in "the resources of treatment in aural disease, 
and we should endeavor to increase the number of our 
remedies in all possible directions. An immediate denial 
of the efficacy of electricity, and a complete rejection of 
it, in the treatment of the diseases now under considera- 
tion, is certainly not a proper way to dispose of the subject. 
I have often made use of the Faradaic current in treating 
persons with impaired hearing, but nearly always after a long- 
continued introduction of vapors into the cavity of the 
tympanum. Most of the patients affirmed that they heard 
better after a frequent application of electricity. In the 
case of others improvement of the hearing was striking, 
and could be proved as well by conversation as by the watch. 

But, in the use of my observations, I exercise the 
strongest possible self-criticism; for very frequently there 
must be considerable distrust in these ear cases. Since it 
is proved that the favorable influence of the vapors appears 
more after, than during the treatment, I take for the 
present such assertions and observations of the patients 
with great care, and I do not yet attempt to prescribe, in 
any detailed manner, -the use of electricity for the treat- 
ment of diseases of the ear. One thing, however, seems 
to me to be quite certain, since its manifestation was too fre- 
quently repeated to be merely accidental. Often in the 
case of those patients whose ears had been Faradized for 
any length of time, the frequency of the vacillations to 
which their acuteness of hearing had been subjected, was 



METHOD OF APPLICATION. 543 

decreased, and the deafness and fatigue formerly occasioned 
by straining to hear, were very much lessened; these phe- 
nomena having appeared before in a striking manner, 
sometimes with, and sometimes without weariness, or a 
desire for food. 

In Faradizing the ear, one conductor, a metallic bar, 
insulated down to its point, is dipped into the meatus, 
which is rilled with warm water, while the other, in the 
form of a copper wire which is covered, and bare at the 
points, is introduced through the catheter some distance 
into the tube. The parts which the electric current will 
preeminently influence in this manner, are the membrana 
tympani, and above all the middle part of the ear, 
and, in the latter, the interior muscles of the ear, viz., 
the tensor tympani and the stapedius, as also the muscles 
of the Eustachian canal. If we were able to perceive the 
pathological conditions and functional anomalies of these 
muscles in the living body, it is highly probable that the 
indications of the applications of electricity in diseases of 
the ear could be formed more definitely. That muscular 
diseases also appear in the ear, is not only to be supposed 
a priori, but we have an anatomical proof of it in the case 
of the muscles of the cavities of the tympanum, since I 
frequently found them diseased in my dissections of the 
ear, having undergone cartilaginous, fatty, and granu- 
lar changes. What place must be assigned to the internal 
muscles of the ear for the physiological and pathological 
state of the sense of hearing, has by no means been 
exactly and definitely determined. At any rate, it will be 
no insignificant and unimportant one. Heretofore these 
muscles have been considered a kind of accommodating 
apparatus. I would like to remind you that a series of 
morbid phenomena in the eye which, heretofore, have been 
considered nervous and indefinable, now appear as lesions 
of accommodation, i. e., anomalies of the muscles of 



544 FARADIZATION OF THE EAR. 

accommodation. It is conceivable that a similar condi- 
tion obtains in the ear. The above-cited investigations 
concerning the influence of electricity may perhaps be ex- 
plained in this manner. 

Duchesne and Erdmann speak, in the application of elec- 
tricity to the ear, of "Faradization of the chorda tympani," 
against which idea it may be said that this nerve, of all 
others which here come under consideration, seems to 
have, at any rate, the very smallest importance to the ear 
and its functions. 

In the Faridization of the ear, in the manner above described, 
most patients experience a painful contraction in the half of the 
tongue corresponding to the point of application, together with a 
peculiar sensation in the ear, like the sound from cooking, the rustling 
of a fly, as well as a darting pain in the ear. This does not usually 
pass to the apex of the tongue, but usually stops short of this. More 
rarely, even when a stronger current is used, there is a metallic or 
prickly taste on the tongue. The pain in the ear depends of course 
on the irritation of the branches of the tri-facial, which supply the 
auditory canal and the outer surface of the membrana tympani. The 
sensation on the tongue is produced by the chorda tympani^ which as 
is well known soon after its passage through the Glaserian fissure, 
unites with the lingual branch of the fifth. It is peculiar, that the 
sensation in the tongue does not appear in all persons. On the other 
hand, patients who have no sensation in the tongue during the applica- 
tion, usually have considerable pain in the ear, even when a very 
weak current is employed. 

I was once able to experimentally observe the influence of the 
chorda tympani, upon the tongue of the human subject. I had 
renewed several polypoid excrescences from the auditory canal of a 
young man, and finally the membrana tympani was plainly seen 
greatly swollen, and with a fissure like perforation on its posterior and 
upper portion. As I cleaned the blood and pus away from the mem- 
brane with a camel's-hair pencil, the patient suddenly spoke of a 
decided sensation upon the tip of the tongue of the same side. On 
examining the part again, I distinctly saw a white point posteriorly 
and above on the membrana tympani, where it was perforated, which 



HEARING TRUMPETS. 545 

from its appearance and position, I was obliged to consider as the 
exposed chorda tympani nerve. I now made a very fine point to the 
pencil, and when I touched the white spot, the patient immediately 
spoke of a very decided feeling on the tip of the tongue, which he 
described as a peculiar pricking sensation, as the "same kind of a 
shaking that is experienced when the brakes are applied to railroad 
cars in motion." This sensation was always confined to the tip of 
the tongue, and the patient, who was very intelligent, said there was 
no sensation of taste. 

Very recently the constant or galvanic current has been 
employed in aural surgery. Brenner* of St. Petersburg, 
speaks very favorably of its use in the diagnosis and treat- 
ment of aural disease, after very extended experience with 
it. The observations and experiments of Schwartze* and 
B. Scbu/Zy 3 of Vienna, have, however, led them to a dif- 
ferent conclusion. I have no experience of my own on 
the subject. 

Hearing Trumpets. 

I may here say something of the mechanical assist- 
ances which facilitate intercourse with those whose hearing 
is very much impaired. These are appliances which cause 
either the human voice or musical tones to be more easily 
perceived. 

Up to the present time, unfortunately, speculative me- 
chanics have undertaken the construction of apparatuses 
for assisting the hearing, much more frequently than men 
educated in physical and physiological science. Hence 
the science of acoustics has furnished much less assistance 
to sufferers from aural disease, than that of optics has for 
those with impaired vision. In other words, gentlemen, 
spectacles for the ear are yet to be found. 

i Virchow's Archiv, Bd. XVIII and XXXI. 

2. Archiv fur Ohrenheilkunde, I, s. 44. 

3 Wiener Mediz Wochenschrift, Nos. 73, 77. 

69 



54^ HEARING TRUMPETS. 

You will be surprised at the number of hearing trum- 
pets of various kinds which are to be found in the posses- 
sion of persons with impaired hearing, and very often 
they are of no service to them. For the most cases a tube 
of two to three feet long, made of wire covered with 
stranded leather, with horn extremities, seems to do the 
best service. 

Fig. 40. 




Elastic hearing tube. 

The ear piece should be well rounded off, so as to fit 
the auditory canal of the person using it. Under certain 
conditions, if properly curved, it will stay in the meatus 
of itself. The funnel-shaped mouth-piece should be held 
by the person speaking, near his mouth, without covering 
it, however. It should be small when used for conver- 
sation with one person, but large when designed for general 
conversation, or for considerable distances, when it should 
be of the size of an ordinary funnel, such as is used in the 
kitchen. 

In listening to lectures or sermons, this end should be 
laid on the table before the speaker. Such an ear-trumpet 
can be worn under the collar in the case of men. Similar 
to this leather ear-trumpet, is one of pasteboard, or of 
German silver, which, for the sake of convenience, is 
made in sections, to be joined together when used. Some 
patients, however, are happy and contented with a cow's 
horn, simply adapted to the purpose. 

I have seen some patients who could not understand a 



HEARING TRUMPETS. 547 

word with any kind of an ear-trumpet, while they could 
hear words spoken loudly in the ear when no tube was 
employed. Politzer believes that in such cases the elastic 
cartilage of the ear contributes in conducting the sonorous 
waves upon the bones of the head. Since I have often 
observed that the ear-piece, when made as an oval, slightly 
hollowed disk, which is held on the auricle, did better 
service for some patients than the thin extremity ordinarily 
used for the meatus, I have attempted, in such cases, to 
employ an ear-piece in which the auricle could still be used 
to collect the sounds. I can, however, give no accurate 
results from such experiments. 

An apparatus made of gutta-percha, as a rule, deadens 
tones too much. Those of metal can seldom be perma- 
nently worn, on account of their great resonance. This 
is also the case with all instruments that are worn in the 
ear continuously. They are usually irritating, and pro- 
duce permanent tinnitus aurium. Since most persons 
with impaired hearing are weak enough to wish to conceal 
their infirmity, they prefer hearing trumpets that are so 
small as not to be observed, or those which can be placed 
under the hair. Unfortunately the usefulness of such 
instruments is generally also invisible. 

The ear-clamp, or "Otaphone," said to have been sug- 
gested by Webster, of London, possesses the advantage of 
not being seen, and also of being at times useful. It con- 
sists essentially of a clamp fastened to the posterior aspect 
of the auricle, which serves to cause the ear to project 
further from the head, and it thus causes the reception of 
sounds coming from the front of the listener to be some- 
what easier. As you must have often observed, very many 
deaf persons have a habit of placing the hands or fingers 
behind the ear, and thus pressing the auricle forward when 
they wish to hear a little more distinctly. It is astonish- 
ing what an influence upon the hearing this simple ma- 



548 HEARING TRUMPETS. 

nipulation exerts in some patients. The auricle is often 
pressed very much against the head, especially among 
women, by the bonnet or hair, and thus its elevations and 
depressions are so much flattened out that the functional 
value of the part is nearly lost. The Otophone is pecu- 
liarly adapted for such cases. 

(I am very often asked by physicians, as well as laymen, 
in regard to the value of certain little brass tubes, re- 
sembling miniature trachea tubes, designed to be placed in 
the auditory canal, that have been sold in great numbers 
in this city. I have never seen a person who has been 
benefited by their use, even where the walls of the canal 
have become so collapsed as to very much lessen the caliber 
of the canal. Such cases of collapse are usually preceded 
by morbid changes in the inner parts of the ear, which 
render any increased facility of access of sounds by widen- 
ing the meatus, of no avail. St. J. R.) 

We very often find that patients have a very great dis- 
inclination to the use of any kind of a hearing trumpet. 
Very many are annoyed by such a proof of their infirmity; 
others less vain and egotistical fear that their hearing 
may be made worse by the use of any conductor of sound. 
The latter should not be feared in the use of any properly 
made instrument. On the contrary, cases are not infre- 
quently met with where partially deaf persons, who have 
given up hearing with one ear at least, have been able by 
the use of a listening tube, to acquire such an amount of 
hearing that they could dispense with the use of the trum- 
pet under some circumstances, when in the beginning 
they could scarcely hear even by its aid. Not a few 
patients who have begun to withdraw themselves from 
ordinary social intercourse, have had a new life given them 
by the use of an appropriate hearing-trumpet. The fact 
that a great convenience is thus afforded the friends of the 
patient, is also a matter of some importance. 



LECTURE XXXL 

the examination of patients. 
Post Mortem Examination of the Ear. 

Gentlemen: Before we pass on to a consideration of 
all the points that are to be considered in the examination 
of a case of disease of the ear, I would like to impress 
upon you the necessity of taking careful and complete 
histories of your cases. 

A detailed history of a case, which has been kept during 
the whole course of treatment, until the discharge, or 
until an examination is made on the dead body, is the best 
means of causing a young man to become an accomplished, 
closely observing physician, as well as one able to give 
an unprejudiced opinion. Such a purely objective style of 
examination is also of great value for the subsequent 
practice of the observer, since it compels him to have a 
thorough basis for his opinions, and carries in itself the 
necessity for rigid self-criticism. 

The more exactly and objectively does a physician work 
up the histories of his patients, the greater will be the 
assistance he can render to science, as well as to suffering 
humanity. On the other hand, the less he does this, and 
the quicker he is to make final decisions as to the diag- 
nosis, the earlier and more certainly does he degenerate 
into a mere mechanic, who follows only the beaten track, 
or acquires the self-satisfaction which is so convenient and 



550 MODE OF RECORDING CASES. 

so common among some old physicians. He thus also 
attains an unscientific and purely symptomatic idea of the 
history of a case. 

It is hardly necessary to tell you how indispensable are 
full and exact histories of cases that may run on for years, 
and how important they become at the post mortem exa- 
mination. Nowhere is a thorough and purely objective 
observation of cases more necessary than in the branch of 
medicine so incomplete as aural surgery, one, we may 
say openly, which has been very inaccurately studied. 
Every honest, unprejudiced observer is here a gain for 
science, because he collects new facts which may serve as 
the test of those already furnished, and their union renders 
our knowledge gradually more and more complete. But 
it is not enough to make a few scanty notes, and at the 
close to give the preconceived diagnosis, but all the de- 
tails that the case demands should be furnished, strictly 
following them out, without any prejudice. All this is 
best attained by some previously prepared plan or scheme. 
The one which I employ is the following: 

Name; age; occupation; residence; history (duration, 
earlier and later symptoms, in short, the course of the 
affection; pain; tinnitus; discharge; it is important to 
learn if the tinnitus was present before the impairment 
of hearing, or if it appeared with it, if it increases or 
decreases with the diminution and impairment of hear- 
ing; how long the present condition of the hearing 
has existed; if it is variable in degree or always the 
same; probable cause; constitutional disease; present 
condition; hearing distance for the watch and conversa- 
tion; conduction of sound through the bones; patient's 
own voice, is it heard by himself clearly or not; mode of 
speech; what influences cause the tinnitus and impaired 
hearing to increase; objective examination; auditory canal; 
cerumen; membrana tympani (its brilliancy, the light 



MODE OF RECORDING CASES. 55 I 

spot, color, handle of the malleus, curvature, projection 
in front or behind the short process of the malleus); 
pharynx; catheterization and air bath (changes in hearing 
caused by these) ; general condition; hereditary tendency; 
diagnosis; treatment. 

You see, gentlemen, that so many things are to be ob- 
served at the first examination of a patient, that it will 
consume a great deal of time. You should never allow 
the patient himself to furnish his case. He is apt to un- 
derrate important facts, and overestimate indifferent ones. 
You should ask the questions, and cause the patient to 
answer merely, and, even then, you will often be obliged 
to break up a tedious disquisition, and remind the pa- 
tient of your question. It is almost incredible how much 
trouble it sometimes costs -to get a direct answer, espe- 
cially as to the duration of the affection. A patient 
whose hearing has been impaired for years, will not unfre- 
quently tell you he has been deaf "for about six weeks/' 
after he has excused himself a great many times for 
being deaf at all, or he will say that he has "only a little 
noise in his ears," although he is scarcely able to hear 
the questions asked him. After the patient has stated 
when his affection began, it is well to ask him if he had 
perfectly good hearing in both ears before that, and you 
will often be surprised how far back the real time of the 
beginning of the disease will be found to be. There 
are other points where inconsistencies will occur, so that 
you will not always come to a speedy conclusion as to 
the condition of things. 

(In interesting cases, and where the patient is intelligent, I gene- 
rally cause the patient to write me his own history of the case. In 
this way we may often get a thorough account, with less trouble than 
by the use of one's own pen and voice). 



552 POST MORTEM EXAMINATION OF THE EAR. 

Examination of the Ear on the Dead Subject. 

I need not speak to you, gentlemen, of the importance 
of pathological anatomy, for medical science, any more 
than I need to tell you that the sun illuminates the earth 
over which it shines. We have already seen how late it 
was in the history of aural medicine and surgery before 
pathological investigation of the ear was undertaken, and 
that the slow and late development of this part of our 
science resulted as it necessarily must, from this neglect 
of the appearances of the organ on the cadaver. 

Since the profession in general has an exaggerated idea 
of the difficulty of making a post mortem examination of 
the ear, and since if there be not a certain method in 
opening the organ, the connection of the parts may be 
easily destroyed, and a view of the actual state of things 
rendered difficult, I have thought it would be useful to 
demonstrate to you the proper way of making a section 
of the organ of hearing. 

I must first dissent from the commonly accepted opinion, 
that a thorough examination of the ear cannot be made 
without great mutilation of the subject. It is true that 
we can not make an exact examination without removing 
the parts from the head, but this may be done in such a 
manner that scarcely any unpleasant appearance will result. 

We attain the desired end in the simplest, quickest, and 
most thorough manner, if, after removing the calvarium and 
cerebrum, we make two vertical sections with the saw, one of 
which passes a little behind the mastoid process, and the 
other through the lesser wing of the sphenoid bone, and the 
middle of the zygomatic process. The two may then be 
run into each other through the base of the skull. If we 
then exarticulate the lower jaw, and separate the atlas and 
occiput, we may isolate all the interesting parts by a few 
vigorous cuts with the knife. 



POST MORTEM EXAMINATION OF THE EAR. 553 

These parts are the petrous bones with the transverse 
sinuses, the Eustachian tubes, and the pharyngeal mucous 
membrane, from the fauces to the anterior surface of the 
spinal column. Since the face, which has been deprived of 
its support, sinks back towards the occiput, we must fill up 
the space with straw or a bit of wood. We may avoid all 
unpleasant mutilation of the subject, in this thorough re- 
moval, if we leave the auricle, and only carry one of the 
incisions, the posterior, through the integument. We 
may then dissect up the flap, and after the removal of the 
parts desired, unite the incision below the ear by satures. 
If the hair of the subject be made available we may so 
arrange matters that such a cadaver may be examined by 
even the most distrustful eyes, without the discovery of 
any defect. 

It is not so well, if, from any reason, e. g. y the want of a 
saw that is large enough, we are obliged to remove the 
temporal bone alone. For this purpose, we cause the 
above described incisions to converge towards the sphenoid 
bone, so that this and the basilar portion of the occipital 
bone are not cut through. We then, by means of a chisel, 
break through the temporal bone, assisting in the separa- 
tion with the scissors, which should be introduced as far 
anteriorly as possible, and below towards the pharynx, in 
order to retain the most necessary portions of these parts. 
In this way we only get a view of the naso-pharyngeal 
space as it is divided, and not in its proper relations, as 
by the former method. 

If we are obliged to avoid all trace of the resection of 
the skull, we may leave the squamous portion of the tem- 
poral bone in situ, and separate the petrous portion by 
means of a chisel and hammer, so that such a section is 
made of the bony meatus, immediately in front of the 
membrana tympani, as is seen in Fig. 2, page 22. 

After having removed the temporal bone in one way or 
70 



554 POST MORTEM EXAMINATION OF THE EAR. 

another, it will be then best, after taking away all that is 
superfluous from the preparation, to first remove the an- 
terior wall of the auditory canal, by means of the scissors 
and bone forceps, in order to get a view of the outer sur- 
face of the membrana tympani. After examining the 
auditory canal and the outer surface of the drum, we turn 
to the mucous membrane of the pharynx, and the carti- 
laginous portion of the tube. We should make several 
sections in order to study the condition of these latter 
parts. These are made at right angles to the axis of the 
tube, with a sharp knife. In order to expose the whole ex- 
tent of the tube, with its muscles, we should remove the 
zygoma, the anterior portion of the squamous portion of 
the temporal bone, and the greater wing of the sphenoid, 
with the bone forceps and saw. For the purpose of more 
exact examination, it is well to cut off the cartilage of the 
tube in connection with its lateral attachment to the skull, 
when the different sections can be kept unchanged. By 
this method we may best recognize the arrangement of 
both the muscles of the tube. In order to get a more 
extended view of the mucous membrane of the tube, in 
its whole course, we open the membranous portion with 
the scissors. When the osseous part of the tube has been 
reached, it is removed piece by piece, and thus we test the 
condition of its mucous membrane, and the width of the 
canal. In doing this we keep a little outward towards the 
squamous portion of the temporal bone, in order to pre- 
serve the whole length of the tensor tympani muscle. 
The nearer we come to the cavity of the tympanum, the 
slower should we work, and we should always observe the 
swellings, cord-like, or fold formations near the tympanic 
orifice of the tube, which frequently pass over to the 
membrana tympani itself. 

I usually leave the uppermost portion of the tube 
unopened, and first remove the roof of the cavity of 



POST MORTEM EXAMINATION OF THE EAR. 555 

the tympanum, in order to better examine the parts from 
above. We should then remember that the head of the 
malleus is found close under the roof of the tympanic 
cavity, and avoid any contact with it with the bone forceps. 
We should therefore begin posteriorly to open the tegmen 
tympanic that is, from the mastoid antrum. The point of 
an ordinary strong pair of forceps may*foe usually em- 
ployed to expose the middle ear, after the bone nippers 
have made an opening. 

When we have a sufficient view of the cavity of the 
tympanum from above, we should test the mobility of the 
articulation of the malleus and incus, by means of a fine 
pair of forceps, and observe any adhesions or abnormal 
connections that may exist. If there are any such, and 
we wish to obtain a more exact view as to their extent, and 
so on, without injuring the preparation, it will be best to 
saw through the anterior portion of the pyramid at a plane 
which meets the membrana tympani at about a right angle. 
The anterior portion that has been sawed off on the floor 
of the cavity, is then broken off, and we may inspect it 
laterally, and from below, without disturbing the mem- 
brana tympani from its position, and the adhesions from 
their connection with it. (See Fig. 8, page 70.) Such sec- 
tions of the cavity of the tympanum are in many cases 
very instructive. Since such a section passes, through a 
portion of the labyrinth, we should first examine this part 
in a manner to be subsequently mentioned, if, indeed, we 
find any indication for looking at it at all. 

If it be preferred to get a complete view of the inner side 
of the membrana tympani, and of the wall of the laby- 
rinth, the temporal bone must be divided into two parts — 
the pyramid on one side, the squamous portion and mas- 
toid process on the other. For this purpose we first cut 
through the tendon of the tensor tympani, and separate, 
by means of a delicate little knife, the articulation between 



556 POST MORTEM EXAMINATION OF THE EAR. 

the stapes and incus. After the cells of the mastoid pro- 
cess have been broken into, from behind and above, we 
turn to the lower surface of the petrous bone, where the 
transverse sinus, with its transition into the jugular vein, 
and the internal carotid, with its venous sinus, are more 
exactly examined. If, now, the lamella between the 
osseous part of #he tube and the carotid canal, be divided 
by sharp-cutting bone nippers, and then the wall of sepa- 
ration between the latter and the fossa for the bulb of the 
jugular vein, the preparation usually divides into the two 
parts desired. We have only to make a few cuts with the 
scissors through the soft parts of the mucous membrane 
of the cavity, and the facial nerve. 

The outer half of this section shows a part of the cells 
of the mastoid process, and the inner surface of the mem- 
brana tympani, with the malleus, incus, and anterior wall 
of the bony Eustachian tube. If the incus be carefully 
separated from its articulation with the head of the mal- 
leus, we see the whole extent of the chorda tympani, in its 
course through the cavity of the tympanum, the insertion 
of the tensor tympani, and the two pockets or pouches. 
We may then test the contents of the latter, the existence 
of adhesions, etc.; we may also examine the condition of 
the membrana tympani, the degree of its transparency, 
and finally, if we please, remove it from its attachment. 
For the purpose of a microscopic examination it is usually 
enough to cut out a piece. 

The other, and inner half of our preparation, consists 
chiefly of the pyramid, and affords a view of all the parts 
of the labyrinth wall, as in Fig. 7. Frequently, by the 
above described opening of the temporal bone, the eni- 
mentia pyramidalis is opened so that the stapedius muscle 
is exposed, and it, as well as the tensor tympani, may be 
examined microscopically. 

We now examine as to the condition of the fenestra 



POST MORTEM EXAMINATION OF THE EAR. 557 

rotunda, its canal and its membrane, and as to the mobility 
of the stapes, by delicate traction upon the tendon of its 
I muscle, and by a very careful examination of the crura or 
sides of the bone, which easily break off if the bone be 
abnormally fixed. We can only get a more thorough view 
of the membrane of the fenestra rotunda and ovalis, from 
the vestibule and cochlea. They can only be examined 
microscopically by opening the labyrinth. 

In many cases it will be very interesting for us to know 
how far the stapes may be movable in its oval fenestra. 
Pressure upon its head, and seizure of the crus of this 
little bone by the forceps, may easily give us a false con- 
clusion. Such attempts at an examination should only be 
made with the greatest care. The enveloping membrane 
of the base of the stapes may be completely ossified and 
changed to a thin bony plate, so that the stapes during 
life could undergo no motion at all, and yet, it appear 
movable at the first motion with the forceps, because we 
thus may have broken the delicate bony plate. Politzer* 
therefore, advises that air be alternately blown into and 
drawn from the auditory canal, before it is removed, 
through an india-rubber tube. If we have previously 
opened the vertex of the upper semi-circular canal, and 
placed a drop of fluid there, upon which a cone of light 
is thrown, we see, if the stapes be movable, the point 
of light change its position, on the forcing in the air and 
withdrawing it from the auditory passage. If this do not 
occur, a small manometric tube, filled with a solution of 
carmine, is hermetically introduced into the semi-circular 
canal. The slightest motion of the stapes will be now 
perceived by a rising and falling of the fluid in the 
manometer. If no motion occur, there is no doubt of 
the immobility of the stapes, provided there be no ab- 
normal hindrances to its motion in the peripheral parts, 

1 Wiener med-Wochenschrift, 1862, s. 2, 14. 



5$8 POST MORTEM EXAMINATION OF THE EAR. 

which may be very easily determined by opening the audi- 
tory canal and cavity of the tympanum, and examining 
them. 

In cases where much depends upon the examination of 
the internal ear, and the preparation is still recent, it is 
best to undertake the examination of this part before that 
of any of the other. If it be an old specimen it should 
be first placed for some days in a wine-colored solu- 
tion of chromic acid, or of the chromate of potash. (The 
latter is to be preferred, on account of the dulling of the 
instruments which the chromic acid solution causes. I 
would also call your attention to the fact that otoliths, 
consisting of carbonate of lime, are dissolved by weak 
solutions of chromic acid.) 

We first examine the auditory nerve by breaking into 
the internal auditory canal from above, and with it ex- 
posing the facial. In the microscopic examination parallel 
examinations of the facial and other nerves, are much to 
be advised. If the Fallopian canal be followed from the 
cavity of the tympanum, and the bending of the facial, 
we have the most important parts of the labyrinth, the 
cochlea and vestibule, under this nerve. They may be 
very readily opened from above, by removing the bony 
plate in layers, by means of a small chisel. 

It is best to examine the cochlea first, as being the most 
accessible and finer structure. This lies in a median di- 
rection from the facial nerve, towards the carotid artery 
and the tube. When the bony covering has been removed, 
so that the lamina ossea spinalis are exposed, we should 
only break off the base of the spiral, which lies towards 
the meatus auditorius internus, in order to remove the 
whole modiolus with the spiral layer en masse. We will 
not need any assistance with a dissecting needle or point 
of the knife on the cupola, which lies close to the ten- 
sor tympani, as often as on the periphery of the spiral 






POST MORTEM EXAMINATION OF THE EAR. 559 

turns. If the contents of the cochlea be now placed in 
serum, or a weak solution of common salt, the mem- 
branous spiral turn is brought out, and besides making a 
general examination with a magnifying glass, we may cut 
off a part for microscopic examination. Laterally, with 
relation to the facial nerve, that is, towards the squamous 
plate, lies the vestibule, with the semi-circular canals pro- 
ceeding from it. The upper canal is opened on the ex- 
posure of the cavity of the tympanum, at any rate when 
the labyrinth cavity is opened. It takes a great deal of 
time to chisel off the whole covering of the semi-circular 
canals, throughout their whole course, as Voltolini 1 advises, 
and as a rule it is not necessary, because we may remove the 
membranous portion from its bony tubes, and then exa- 
mine them. We finally test the condition of the fenestra 
ovalis from within, the transparency of the membranous 
ring surrounding the base of the stapes, as well as the 
membrana tympani secondaria. These parts may then be 
conveniently removed, and a microscopic examination of 
them be made. 

Thus we may examine the different parts of the ear, not 
only as separated, but also in connection with each other. 
This method of dissection is also to be advised in the 
study of the anatomy of the ear. The brain should also 
be examined in some cases, especially the fourth ventricle 
from which the auditory nerve springs. 

Of course in some cases we are obliged to deviate more 
or less from the method just given. Where collections 
of piis exist they should be carefully removed by means of 
a camel's-hair brush, and by pouring water over them. It is 
also advisable, after the secretion has thus been removed, 
to place the preparation in alcohol for a few days, before 
examining the parts any further, in order to harden them. 

The usual instruments for a post mortem examination 

1 Die Zerlegung un Untersuchung des Gehoorganes an der Leiche. 



560 POST MORTEM EXAMINATION OF THE EAR. 

are required for such an examination, with the addition of 
one or two bone nippers, made like nail nippers. Luers 
ingenious resection forceps, like a double gouge (Pince 
gouge de Luer) are very excellent. We may work with them 
very safely, and cut the smallest and hardest portions of 
bone, at the same time protecting the neighboring parts. 

For some fine dissections, as well as in laying open the 
cavity of the labyrinth, I use a graver's tool and a hand 
chisel, with variously shaped cutting surfaces. We can 
work very well with a hammer and small chisel, yet, unless 
great care be taken, many preparations will be destroyed 
with them. 

The saw should only be used in the preparatory parts 
of the dissection, since the finest saw will prevent a good 
view of the parts by the saw-dust, and the twisting and 
stretching of the soft parts caused by them. The same is 
true of files and rasps. A vice is often needed to hold the 
preparation. A board with sides, against which the pre- 
paration may be pressed when necessary, will perhaps be 
sufficient in many cases. 



INDEX. 



Abscess, cerebral, 440. 

metatastatic, 444. 

of sudoriparous glands, 102. 

secondary in external auditory canal, 

113. 
follicular, 95. 
Abrahams, instruments for dilating auditory 

"canal, 127. 
Accommodation of ear, 544. 
Acuteness of hearing, method of ascertain- 
ing, 249. 
excessive, 256. 
Adhesions in cavity of tympanum, 273 ; case 

of rupture of, 344. 
Agnew, C. R., case from, 471. 
Air douche, 221. 
Alum, causes furuncles, 97. 
Ammonia, muriate, injection of vapor of, 348. 
Annulus tympanicus, 29. 
Anchylosis of stapes, 222. 
Aristotle on Eustachian tube, 200. 
on perception of ideas, 2. 
Arnold on sub-auricular glands, 179. 
Artillerists, method employed by to prevent 
rupture of membrana tym- 
pani, 14S. 
case of nervous deafness in, 500. 
Artery, stylo-mastoid, 167. 
Artificial membrana tympani, 421. 
Aspergillus glaucus in ear, 108. 
Astringents in otorrhoea, 459. 

otitis externa, 129. 
Auricle, calcareous depositions in, 57. 

physiognomic importance of, 14. 
malformations of, 57. 
in gout, 56. 
wounds of, 51. 
tumors of, 5 2. 
eczema of, 52. 
contusions of, 49. 
anatomy of, 11. 
size of in embryo, 13. 
in adult, 14. 

71 



Aural specula, 63, 286. 

Auditory canal, external blood vessels of, 24. 
nerves of, 24. 
narrowing of, 126. 
examination of, 58. 
length of, 18. 
external anatomical relations 

of, 22, 47. 
exostosis and hyperostosis 

of, 129. 
is closed at birth in dogs 

and cats, 15. 
of turkey, 15. 
lining membrane of, 21. 
glands of, 21. 
Aural disease, importance of, 4. 
neglect- of, 6. 
surgery, needs of, 9. 
Aural catarrh, chronic, pathology of, 281. 
symptoms of, 289. 
acute, treatment of, 275. 
prognosis of, 272. 
Auscultation of ear, 214. 

Baths, Turkish, 279, 374. 

Russian, 279. 
Bathing, effect of upon ears, 374. 
Blisters in aural disease, 120. 
Bonnafont on paracentesis of membrana tym- 
pani, 390. 
Bochdalek on Rivinian foramen, 27. 
Bougies, Eustachian. 
Boxing ear causes rupture of drum, 147. 
Buchanan, Thos., on cerumen, 76. 

Carbonic acid gas on membrana tympani, 359. 
Caries of petrous portion of temporal bone, 

435> 447, 45°- 
of bone near jugular vein, 158. 
of wall of carotid canal, 165. 
Cases of inspissated cerumen, 83, et seq.^ of 
exostosis, 131 ; of fracture of malleus, 
152; of rupture of adhesions in middle 



5 62 



INDEX. 



ear, 345 5 of use of Politzer's method, 
245 5 of infantile aural catarrh, 407 ; of 
pulsation of membrana tympani, 413 ; of 
use of artificial membrana tympani, 428 $ 
of cerebral abscess, 437 5 hemorrhage from 
transverse sinus, 443; of post aural in- 
flammation, 464 5 of removal of seques- 
trum from internal ear, 471 ; of foreign 
bodies in ear, 485; of hysterical disease of 
ear, 495 5 of nervous deafness, 500, et seq. $ 
of tinnitus aurium, 520; method of re- 
cording, 551. 
Catarrh, definition of, 264. 
acute aural, 265. 
pharyngeal, 315. 
chronic aural, 337. 
tubal, 319.- 
nasal, 315. 

naso-pharyngeal, 296. 
acute purulent, 380. 
Catheter, Eustachian, use of, 199, 201, 221. 
Caustic holder, 482. 
Cavity of tympanum in foetus, 175. 

measurements of, 171. 
section of, 171. 
mucous membrane of, 

173- 
topography of, 170. 

walls of, 155. 

relations of, 155. 

view of, inner wall of, 

163. 

deficiency in floor of, 

158. 

Celsus, used gargles in aural disease, 364. 

Cerumen, inspissated, 81, 88. 

amount of, 79. 

diminution of, 76. 

Cerebrum, abscess of, 159. 

disease, aural affections supposed 

to be, 268. 

Cholesteatomata in middle ear, 449. 

Cleland, Archibald, method of examining 

ear, 66. 

on catheterization, 200. 

Chorda tympani, abnormity in, 325. 

Clarke, E. H., aural douche, 95. 

on aural polypi, 476. 

on perforation of membrana 

tympani, 380. 

Cleft palate, effect on hearing, 301. 

Cold, effect of upon ear, 107. 

Compression pump, 226. 

Compressed air, value of, 360. 

Conta, Von, on use of tuning fork, 255. 

Counter irritation, 361. 

Czermak on rhinoscopy, 

Deafness, moral effect of, 3. 
Deaf-muteism, 533. 



Deaf-mutes, instruction of, 537. 
Dentition, accompanied by irritation of ex- 
ternal auditory canal, 106. 
Deglutition, effect on Eustachian tube, 187, 

191, 300. 
Diagnostic tube, 215. 
Diphtheritic otitis, 376. 
Douche, aural, description of, 94. 

use of in acute affections of 
the ear, 382. 
nasal, 368. 
Duchesne on Faradization of chorda tym- 
pani, 544. 

Ear drops, burn from, 107. 

Ear muffs, 107. 

Eczema of auricle, 52. 

Electricity in disease of labyrinth, 517. 

in aural disease in general, 541. 
Emphysema, sub meningeal, 160. 

of the neck, 209. 
Emboly, 435. 

Erhard on artificial drum, 426. 
Eustachian catheter, 213. 
Eustachian tube, 180. 

mucous membrane of, 183. 

isthmus of, 187. 

section of, 182. 

in child, 184. 

caliber of, 185. 

case of widening of, 332. 

closure of, 287. 

muscles of, 188. 

more permeable in dry 
weather, 333. 

dilatation of, 357. 

stricture of, 387. 
Exostosis in auditory canal, 130. 

Fabricius Hildanus, 70. 
Facial nerve, 166, 

paralysis, 441. 
Fallopian canal, 166. 
Faradization of the ear, 542. 
Fenestra rotunda, 164. 

ovalis, 161. 
Fissure, petro-squamosal, 161. 
Fluids, injection of into middle ear, 351. 
Foramen of Rivinius, 27. 
Forceps, angular, 74. 
Forehead band, 68. 
Foreign bodies in ear, 484. 
Fossa, Rosenmiiller's, 309. 
Fracure of malleus, 151. 
Fungi in auditory canal, 87, 108. 
Furuncles in auditory canal, 96, 101. 

Galvano caustic, perforation of membrana 

tympani by, 391. 
Ganglion, Otic, 198. 



INDEX. 



563 



Gargling, proper method of, 364. 
Gerlach on membrana tympani, 43. 
Glands enlarged in otorrhcea, 109. 
Glycerine, use of, 76. 
Gruber on membrana tympani, 44. 

myringodectomy, 385, 389. 

injecting middle ear, 243. 
Gull on thrombus in transverse sinus, 117. 
Guyot, first to use Eustachian catheter, 200. 

Hallucinations, aural, 531. 

Hearing trumpets, 545. 

Henle, on circumflexus palati muscle, 191. 
osseous meatus, 17. 

Hemorrhage into middle ear, 442. 

Hereditary tendency to aural disease, 318. 

Hewitt, Prescott, case of otorrhcea, 457. 

Hinton, of London, on treatment of otor- 
rhcea, 462. 

Hildreth, J. C, case of rupture of adhe- 
sions, 344. 

Hoffman recommended concave mirror for 
examining the ear, 71. 

Huschke on membrana tympani in embryo, 
27. 

Hyrtl on fracture of malleus, 152. 
Rivinian foramen, 26. 
blood supply of internal ear, 515. 

Hysterical disease of the ear, 491. 

Hyperostoses of auditory canal, 129. 

Hyperassthesia of ear, 532. 

Inhaler, iodine, 247. 
Intra-auricular pressure, 268. 
Injuries of membrana tympani, 151. 
Intermarriage, cause of deaf-muteism, 539. 
Itard, aural specula, 62. 
Internal ear, anatomy of, 493. 
Incus, excretion of, 357. 
Integument, dryness of, its relations to secre- 
tion of wax, 78. 
Infantile aural catarrh, 392. 

otitis, diagnosis of, 401. 

symptoms, 403. 

treatment, 405. 
Isthmus tubae, 358. 

Joux on physiognomic significance of auri- 
cle, 14. 

Jugular vein, contiguity of, to cavity of tym- 
panum, 158. 

Kramer, aural specula, 62. 

on inflammation of cutis, 79. 

nervous deafness, 497. 
Koppe on aural delusions, 531. 
Kolliker on mucous membrane of cavity of 
tympanum, 174. 

Labyrinth, anatomy of, 493. 



Labyrinth, inflammation of, 513, 516. 
Lavater on physiognomic significance of auri- 
cle, 14. 
Lebert on inflammation of venous sinuses, 446. 
Leeches, rules for use of, 123, 125. 
Local blood letting, 464. 
Life insurance companies, relations of to cases 

of otorrhcea, 456. 
Ligament, malleo-maxillary, 157. 
Light spot, triangular, 39. 
Luschka, on ulcerations of petrous bone, 1 60. 
Lucae, on conduction of sound through bones 
of head, 258. 

glands in cavity of tympanum, 1 74. 

respiratory movements of drum, 1 94. 

purulent catarrh, 375. 
Lymphatics under mastoid, 179. 

Malleus, fracture of, 151. 

anterior muscle of, 157. 
exsection of, 357. 
Manometer, aural, 244. 
Mastoid process or cells, 169, 178. 

in chronic aural catarrh, 335. 
trephining, 467. 
Mayer, L., on vessels of Eustachian tube, 183. 
Meatus, osseous, 16. 
Membrana tympani, anatomy of, 26. 
layers of, 43. 
vessels and nerves of, 46, 

123. 
illumination of, 63. 
perforation of, 119. 
paracentesis of, 145. 
diseases of, 138. 
deficient development of, 

27. 
shape of, 29. 
diameter of, 29. 
curvature of, 34. 
color of, 37. 
vilii, 42. 
papillae, 42. 
loss of substance, 160. 
pockets of, 32. 
injuries of, 149, 272. 
movements, 234. 
in acute aural catarrh, 209 
paracentesis, 276. 
in medico-legal cases, 

328. 
in diagnosis of disease, 
middle ear, 321, 329. 
collapse of, 326. 
Meningitis from inflammation of external 
auditory canal, 117. 
from inflammation of middle 

ear, 449. 
improper diagnosis of, 109. 
Meniere, cases from, 428, 503. 



5 6 4 



INDEX. 



Middle ear, anatomy of, 154. 
affections of, 157. 
Mirror, concave, 57. 
Moos, apparatus for generation of muriate of 

ammonia vapor, 228. 
Mucous cushion in middle ear, 175, 400. 
Myringitis, 140. 

Miiller, J., on conduction of sounds, 257. 
Muscle, stapedius, 168. 

tensor tympani, 168. 
levator palati, 193. 

Naso-pharyngeal catarrh, 401. 
Nasal douche, 369. 
Naso-pharyngeal space, 308. 
Nares, posterior, 311. 

syringe, 369. 
Nebulizer, nasal, 309. 
Nerves of middle ear, 195. 

of internal ear, 495. 

pneumo-gastric, 159. 

glosso-pharyngeus, 159. 

facial, 167. 
Neuralgia from catarrh, 314. 
Nervous deafness, 496. 
Nomenclature of aural disease, 104. 
Nostril, injection of, 367. 
Nitrate of silver in furuncles, 99. 

on membrana tympani, 360. 

Oils, value of in aural disease, 122. 
Ossicula auditus, 154. 

development of, 176. 
Osseous meatus, relation to lower jaw, 
Osteo phlebitis, 445. 
Otaphone, 547. 
Otalgia, 532. 
Otorrhcea, 434. 

prejudice against treatment of, 114, 

1 1 9'. 473* 
prognosis of, 118. 
constitutional treatment of, 463. 
Otoscope, 215. 

interference, 263. 
Otitis externa, 103, 105, 109, 113, 118. 
consequences of, 116. 
media chronica, 411. 
Otic ganglion, 198. 
Othatomata, 50. 

Paracusis Willisiana, 256. 
Paracentesis of membrana tympani, 276, 383. 
Periostitis of external auditory canal, 103. 
Phlebitis from aural disease, 446. 
Pharynx, structure of, 297. 

nerves of, 314. 

examination of, 302. 
Pharyngitis, granular, 303. 
Pharyngeal sputa, 310. 
Pharynx, cauterization of, 361. 



Pockets, anterior and posterior, of membrana 

tympani, 32. 
Politzer on calcareous degenerations, 414. 

perforations of membrana tym- 
pani, 414. 
artificial membrana tympani, 427. 
retraction of tensor tympani, 288. 
method of inflating ear, 234. 
cases of use of, 89, 245. 
tensor palati, 191. 
size of membrana tympani, 73. 
Post, A. C, on post aural inflammation, 465. 
Post mortem examination of the ear, 552, tt 

seq. 
Poultices, improper use of, 121. 
Probing Eustachian tube, 359. 

the ear, danger of, 149, 453. 
the middle ear, 225. 
Polypi, nasal, 316. 
aural, 475. 
removal of, 480. 
Pulsation on membrana tympani, 
Purulent catarrh, 375. 

Quinine, effect of upon the ear, 499. 

Rau, on objections to catheterization, 224. 

spectacle forceps, 229. 

bougies for Eustachian tube, 359. 
Respiration, membrana tympani during, 194. 
Reflex irritation from foreign bodies in ear, 490. 
Rhinoscopy, 305. 
Rivinius, foramen of, 27. 
Rosenmuller's fossa, 204. 
Rudinger on Eustachian tube, 183. 

Scrofula, its relation to aural disease, 108. 
Scanzoni on deafness connected with Urtica- 
ria, 499. 
Schwartze on respiratory movements of drum, 
194. 
paracentesis of membrana tym- 
pani, 145, 276. 
fungous growths in ear, 108. 
treatment of otorrhcea, 462. 
hemiplegia, 481. 
poultices in furuncles, 121. 
Semi-circular canals, 168. 

disease of, 504. 
Sclerosis of middle ear, 280. 
Semelder on rhinoscopy, 301. 
Sebaceous glands in meatus, 21. 
Sequestrum, removal of from internal ear, 471. 
Sound, conduction of through bones of the 

head, 257. 
Spasm of muscles of Eustachian tube, 209. 
Specialism, exclusive, 9. 
Specula, aural, 63. 

Spheno-salpingo, staphylinus muscle, 188. 
Stapes, situation of, 170. 

articulation of, 162. 



INDEX. 



565 



Streckeisen on infantile aural catarrh, 398. 

case of otitis media, 407. 
Syringing, 90, 93. 

Synechia? in cavity of tympanum, 274. 
Syphilis communicated by catheter, 212. 
cause of nervous deafness, 514. 
Suppuration in the ear, 434, 455. 
Sulcus tympanicus, 28. 
Sun light in examining the ear, 63. 

Tensor tympani, 168. 

secondary retraction of, 288. 
tenotomy of, 288. 
palati, 188. 
Temperature, influence of, 291. 
Thrombus in transverse sinus, 117. 
Tinnitus aurium, 4, 338, 524. 

in insane, 531. 
Tobold, illuminating apparatus of, 306. 
Toynbee, labors of, 7. 

on appearances in labyrinth, 498. 
artificial membrana tympani, 

422. 
articulation of stapes, 162. 
method of inflating cavity of 

tympanum, 233. 
meningitis from otitis externa, 

117. 
impacted cerumen, 88. 
Tonsils, enlarged, 298, 371. 
Tones, power of hearing various, 254. 
Tuning fork as test of hearing, 255. 

in diagnosis, 88, 148, 259. 
Turnbull (London) on Eustachian catheteri- 
zation, 210. 
Tuberculosis existing in connection with otor- 
rhcea, 449. 
of temporal bone, 448. 
Tubal catarrh, 325. 
Tympani tegmen, 159. 
Typhoid fever, deafness after, 500. 

Urticaria, case of deafness in connection with, 

499- 
Umbo, 31. 

Uvula, oblique position of, 304, 442. 



Valsalva, mode of opening Eustachian tube, 

# *3 I >347- 
discoverer of tensor palati, 
Valsalvian experiment, negative, 233. 

dangerous in certain 
cases, 239. 
Vapors, injection of, 348. 
Vasa emmissoria santorini, 179. 
Vertigo in aural disease, 294. 
Venous sinuses, inflammation of, 446. 
Villi on membrana tympani, 43. 
Virchow on inflammation of venous sinuses, 

447- 
othatomata, 50. 
congenital anomalies of auricle, 

57- 
Voltolini on canal to fenestra rotunda, 165. 
inflammation of labyrinth, 516. 
articulation of stapes and fenes- 
tra ovalis, 163. 
perforation of membrana tym- 
pani by galvano-caustic, 391. 
diseases of labyrinth, 498. 
Vomiting in pharyngeal catarrh, 313. 

Warm water, use of in aural disease, 120. 
Water douche to Eustachian tube, 243. 
Wagner on granular pharyngitis, 303. 

central organ of hearing, 497. 
Weir, R. F., on fracture of malleus, 152. 

otalgia, 532. 
Welcker on exostosis, 136. 
Wilde, labors of, 7. 

on light spot on drum, 40. 
on thickening of membrana tym- 
pani, 388. 
on collapse of membrana tympani, 326. 
on obliquity of angles of mouth, 167. 
his polypus snare, 480. 
Wreden on exsection of malleus, 357. 
fungous growths in ear, 108. 
infantile aural catarrh, 408. 
excision of handle of malleus, 

39 1 - 

Yearsley on artificial membrana tympani, 499. 



ERRATA. 

Page 33, 10th line from top, for Glaseri read Glaserian. 

Page 56, 4th line from top, for irruption read eruption. 

Page 94, last line, for aural read nasal. 

Page 99, 11th line from the bottom, for is read #r<?. 

Page 1 24, last line, for Tourteloupe read Hourteloupe. 

Page 188, 3d line from the top, for a/' the Eustachian tube read to the, etc. 

Page 234, 13th line from top, after naso-pbaryngeal insert the word space. 

Page 245, 13th line from top, for we had like means, read we had no means. 

Page 357, in foot note, for No. " 17 " read " 7." 

Page 426, 2d paragraph from bottom, for O. Erhard read /. Erhard. 

Page 434, 15th line from bottom, after of the bone insert leading. 

Page 453, 1 oth line from top, after canal om\t the comma, and insert of. 



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